
Book . D - : f < 



THE 



J- ' 



1 1 a / fe 1 



PATHOLOGY AND TREATMENT 



VENEREAL DISEASES 



INCLUDING THE RESULTS OF RECENT INVESTIGATIONS 
UPON THE SUBJECT. 



BY 

FREEMAN J. BUMSTEAD, M. D., 

LECTURER ON VENEREAL DISEASES AT THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK J SURGEON 
TO ST. LUKE'S HOSPITAL : ASSISTANT SURGEON TO THE NEW YORK EYE INFIRMARY. 



WITH ILLUSTEATIONS ON V^OOD. 




PHILADELPHIA: 
B L A N CHARD AND LEA 

1861. 



^ 






Entered according to the Act of Congress, in the year 1861, by 

BLANCHARD AND LEA, 

in the Office of the Clerk of the District Court of the United States in and for the 
Eastern District of the State of Pennsylvania. 



PHILADELPHIA \ 
COLLINS, PRINTER. 



PREFACE 



The object in the preparation of this work has been to furnish 
the student with a full and comprehensive treatise upon Yenereal 
Disease^ and the practitioner with a plain and practical gnide to 
their treatment. In carrying out this design, theoretical discus- 
sions have been made subordinate to practical details ; and, in the 
belief that the success of treatment depends quite as much upon 
the manner of its execution as upon the general principles upon 
which it is based, no minutiae, calculated to assist the surgeon or 
benefit the patient, have been regarded as unworthy of notice. 

The additions to our knowledge of Yenereal, during the last ten 
years, have been numerous, and in the highest degree important. 
Among the most remarkable, may be mentioned the distinct 
nature of the two species of chancre; the innocuousness of the 
secretion of the infecting chancre when applied to the person bear- 
ing it, or to any individual affected with the syphilitic diathesis ; 
the removal of certain obstacles to a general belief in the conta- 
giousness of secondary lesions ; the fact that syphilis pursues the 
same course whether derived from a primary or secondary symp- 
tom, commencing, in either case, with a chancre at the point where 
the virus enters the system ; the definite period of incubation of the 
true chancre, and of general manifestations; the inefhcacy of the 
abortive treatment of syphilis ; and the phenomena of syphilization 
and their correct interpretation. Several of these topics are entirely 
new within the period mentioned, and upon others much clearer 
views have been obtained; so that our present knowledge of Vene- 



IV PEEFACE. 

real Diseases may be regarded as far more complete and satisfactory 
than at any previous time. As yet, however, these results and the 
investigations which have led to them are, for the most part, scat- 
tered through the pages of medical periodical literature, in our own 
and foreign languages. To collect them into one volume, and 
thus render them more accessible to the American reader, has also 
entered into the purpose of the author. 

162 West 23d Street, New York. 
July, 1861. 



CONTENTS. 



Introduction 



PART I. 

GONORRHCEA AND ITS COMPLICATIONS. 
CHAPTER I. 



TAGE 
17 



Urethral Gonorrhoea in the Male 














39 


Preliminary considerations 












39 


Symptoms .... 












41 


Causes and nature of gonorrhoea 












46 


Treatment 












55 


Abortive treatment 












56 


Treatment of the acute stage 












60 


Treatment of the stage of decline 












64 


Copaiba and cubebs 












72 


Obstacles to success 












78 


Treatment of special symptoms 












80 


CHAPTER 


II. 


Gleet 


83 


Symptoms 














84 


Pathology 














85 


Treatment 














87 


Bougies 










• 




90 


Injections 














92 


Deep urethral injections 














95 


Blisters 






„ 








96 


Separation of the affected surfaces 








J • . . 


97 


CHAPTER 


III. 


Balanitis ..... 


99 


Causes ..... 


99 


Symptoms .... 


100 


Treatment . 














100 



VI 



CONTENTS. 



Phtmosis 

Symptoms 
Treatment 

Circumcision 



CHAPTER IY, 



PAGE 
103 

104 
105 
107 



Paraphimosis 



CHAPTER V 



111 



C H APTE R VI. 



Swelled Testicle 
Causes . 
Seat 

Symptoms 

Pathological anatomy 
Treatment 



CHAPTER VII. 



Inflammation of the Prostate 
Acute prostatitis 

Treatment . 
Chronic prostatitis 

Treatment . 



114 
115 

117 
120 
128 
130 



137 
137 
139 
140 
142 



CHAPTER VIII 



Inflammation of the Bladder 
Treatment 



146 

147 



C H A 

Gonorrhoea in Women 

Causes . 

Symptoms 

Gonorrhoea of the vulva 
Gonorrhoea of the vagina 
Gonorrhoea of the urethra 
Complications 

Diagnosis 

Treatment 



PTER IX. 



149 
149 
152 
153 
157 
160 
161 
163 
164 



CHAPTER X. 



Gonorrheal Ophthalmia 
Frequency 
Causes . 
Symptoms 
Diagnosis 
Treatment 



175 

177 
177 
180 
183 
183 



CONTENTS. 



Vll 



CHAPTER XI, 



GONORRHEAL RHEUMATISM 

Causes 

Seat 

Symptoms 

Diagnosis 

Nature . 

Treatment 



PAGE 

193 
195 
197 
199 
211 
213 
215 



Vegetations 
Treatment 



CHAPTER XII 



218 
220 



CHAPTER XIII 



Stricture of the Urethra . 










222 


Anatomical considerations 










222 


Transitory strictures 










240 


Permanent or organic strictures 










243 


Seat . 










248 


Number . 










250 


Form . 










250 


Degree of contraction 










252 


Pathology of stricture . . . 










254 


Abscess and fistula 










256 


Lesions of the bladder 










258 


Lesions of the ureters and kidneys 










259 


Lesions of the genital organs 










259 


Constitutional effects of stricture 










260 


Symptoms of stricture . 










261 


Causes of stricture 










266 


Diagnosis of stricture 










271 


Exploration of the urethra 










272 


Introduction of the catheter 










276 


Model bougies 










278 


Treatment 










280 


Constitutional means 










280 


Dilatation . 










282 


Continuous dilatation 










287 


Rapid dilatation 










288 


Expansion 


^ 








290 


Rupture 










291 


Caustics 










291 


Incisions 










295 


Internal division 










296 


Perineal section 










299 


Consequences of operations upon strict 


ure 








310 



Vlll 



CONTENTS. 



Treatment of retention of urine 
Puncture by the rectum 
Opening of the urethra 
Puncture above the pubes 
Puncture through the symphysis 
Treatment of extravasation of urine 
Treatment of urinary abscess and fistula 



PAGE 

312 
318 
321 
322 
322 
323 
324 



PART II. 

THE CHANCROID, ITS COMPLICATIONS; AND SYPHILIS. 



CHAPTER I. 

Introductory Remarks ....... 327 

Syphilitic virus . . . . . . . 327 

Is there more than one kind of syphilitic virus ? . . 328 

Constitutional syphilis very rarely occurs more than once in the same 

person . . . . . . . • 348 

Classification of the symptoms of syphilis .... 353 

C HAPTER II. 



Chancres ..... 








355 


Seat of chancres 








355 


Contagion . 








358 


Form of chancres 








361 


Artificial inoculation . . 








363 


Classification of chancres 








366 


Simple chancre 








367 


Infecting chancre 








369 


Mixed chancre .... 








382 


Inflammatory or gangrenous chancre . 








386 


Phagedenic chancre 








387 


Diagnosis of chancres . 








390 


Treatment of chancres . 








394 


General treatment . 








395 


Abortive and destructive treatment 








404 


Topical applications 








417 


Special indications from the seat of chancres 








421 


Chancres of the frsenum 








421 


Urethral chancres . 








422 


Chancres of the vagina and os uteri 








424 


Chancres of the anus and rectum . 








424 


Chancres of the mouth 








425 



CONTENTS. 



IX 



CHAPTER III. 



ections of the liymphati 
mary Sores 


C VESSE 


LS AND 


brANGLIi 


L ATTENDANT U3 


'ON rRi 


426 


Simple bubo 








. 




427 


Virulent bubo . 








, 




427 


Indurated bubo 








. 




430 


" Bubon d'emblee" 








, 




437 


Treatment of buboes 








. 




440 


General treatment 








. 




440 


Counter-irritants 








. 




441 


Compression 








. 




442 


Methods of opening buboes 




. 




443 


Treatment of difficult cases 




, 




446 


Treatment of indura 


ted but 


>oes 




, . 




449 



CHAPTER IY. 

General Syphilis. — Introductory Remarks .... 450 

General syphilis always follows a chancre . . . .450 

Period of incubation of general syphilis .... 452 

Classification of general symptoms ..... 460 

Some of the symptoms of general syphilis are contagious . . 467 

What constitutional symptoms are contagious ? . . . 482 

Syphilis pursues essentially the same course, whether derived from 

a primary or secondary symptom ; in the latter case, as in the 

former, the initial lesion is a chancre . . . .488 



CHAPTER Y. 



Treatment of Syphilis 








494 


Hygiene 








497 


Mercurials 








500 


Fumigation 








505 


Inunction .... 








508 


Salivation . 








510 


Duration of treatment 








517 


Iodine and its compounds 








524 


Syphilization 








533 


Is syphilization an efficient and safe method of treating constitu 




tional syphilis ? . 


538 


How are the facts of syphilization 


to be es 


rplainec 


? 


540 



CHAPTER VI. 

Syphilitic Fever ; State of the Blood ; Engorgement of the Lymphatic 

Ganglia ........ 546 

Syphilitic fever ....... 546 

State of the blood . . . . . . .547 

Engorgement of the cervical ganglia ..... 548 



CONTENTS. 



CHAPTER VII. 



Syphilitic Affections of the 
Syphilitic erythema 
Syphilitic papules 
Syphilitic squamse 
Syphilitic vesicles 
Syphilitic bullse 

Pemphigus . 

Rupia 
Syphilitic pustules 

Acne 

Impetigo 

Ecthyma 
Syphilitic tubercles 
Ulcers 
Treatment 



Skin 



page 
551 
555 
557 
559 
560 
561 
561 
562 
564 
564 
565 
566 
568 
572 
572 



CHAPTER VIII, 

Syphilitic Affections of the Appendages of the Skin 
Alopecia ..... 

Onychia ..... 

Paronychia ..... 



575 
575 

577 

578 



Mucous Patches 
Treatment 



CHAPTER IX 



579 
585 



Gummy Tumors 



CHAPTER X. 



586 



CHAPTER XI. 



Syphilitic Affections of Mucous Membranes 






590 


Erythema ..... 






591 


Ulcers ...... 






591 


Tubercles of the tongue 






594 


Treatment of the affections of the mouth and throat 






596 


Stricture of the oesophagus 






598 


Affections of the stomach and intestines 






599 


Stricture of the rectum 






601 


Affections of the nasal passages 






603 


Affections of the larynx and trachea 






605 


Ajmonia ..... 






605 


Laryngitis ..... 






606 


Ulceration of the trachea . 






608 



CONTENTS. 



XI 



CHAPTER XII. 



Syphilitic Affections of the Eyes . 
Affections of the bones of the orbit 
Affections of the lachrymal passages 
Affections of the eyelids 
Affections of the conjunctiva 
Affections of the cornea 
Iritis 

Infantile iritis 
Retinitis and choroiditis 
Amaurosis 
Paralysis of the motor nerves 



PAGE 

611 
611 
612 
614 
615 
615 
617 
625 
629 
631 
631 



CHAPTER XIII 

Syphilitic Affections of the Ear 



633 



Syphilitic Orchitis 
Diagnosis 
Treatment 



CHAPTER XI Y. 



635 

638 
639 



CHAPTER XY. 

Syphilitic Affections of the Muscles and Tendons 
Muscular pains ..... 
Muscular contraction .... 
Muscular tumors .... 



642 
642 
642 
644 



CHAPTER XYI. 

Syphilitic Affections of the Nervous System 



647 



CHAPTER XYII. 

Syphilitic Affections of the Periosteum and Bones 
Osteocopic pains .... 

Nodes ...... 

Caries and necrosis .... 



652 
653 
654 
657 



CHAPTER XYII I, 



Congenital Syphilis .... 


660 


Etiology ..... 


660 


Transmissibility .... 


663 


Abortion ..... 


664 


Period of development .... 


665 



Xll 



CONTENTS, 



Symptoms ...... 

General aspect of syphilitic infants 

Coryza ...... 

Affections of the skin and mncous membranes 

Onychia ...... 

Suppuration of the thymus gland 

Changes in the lungs .... 

Changes in the liver .... 

Peritonitis ...... 

Affections of the periosteum and bones 

Hydrocephalus . . . . 

Affections of the supra-renal capsules and pancreas 
Prognosis ...... 

Treatment ...... 



PAGE 

670 
670 
670 
671 
672 
672 
673 
674 
676 
676 
677 
677 
677 
678 



ON 



VENEREAL DISEASES 



INTKODUCTION. 

Theke are three diseases, which, from their origin in sexual 
intercourse, have been denominated Venereal, viz : Gonorrhcea ; 
the Contagious Ulcer of the Genitals, or Chancroid; and 
Syphilis. These three affections, for a long period confounded, 
have been, since the commencement of the present century, gradu- 
ally resuming the relations which they held to each other nearly 
four hundred years ago. The medical mind has been travelling 
in a circle, and having completed the round, is now where it stood 
in the last part of the fifteenth and the first of the sixteenth cen- 
tury. The distinction between the above-named diseases which is 
now admitted — certainly by a very considerable number of our 
profession, unsurpassed in intelligence, learning, and experience, 
and including names which have long been acknowledged as the 
highest authority — was fully recognized for twenty or thirty years 
after Columbus discovered the new world. 

The earlier history of venereal diseases has recently been very 
thoroughly investigated, especially by Bassereau, 1 Langlebert, 2 and 
Chabalier, 3 and the conclusions which have uniformly been attained, 
startling as they may in some respects appear, are yet supported 
by such an amount of proof drawn from the original sources, that 

1 Affections de la peau symptomatiques de la syphilis, Paris, 1852. 

2 Recherches historiques sur la doctrine moderne des maladies veneriennes, 
1'Union Med., 1855. 

3 Preuves historiques de la plnralite des affections dites veneriennes, These de 
Paris, 1860 (No. 52). I am indebted to M. Chabalier's very able thesis for many 
of the following facts relating to the history of venereal diseases. 

2 



18 INTRODUCTION. 

the j cannot be called in question ; at all events, no one as jet hag 
denied their correctness, although Bassereau's work has been for 
nearly ten years before the profession. I propose as briefly and 
concisely as possible to state what is at present known upon this 
subject. 

Gonorrhoea has existed among all nations, and from the earliest 
times of which we have any record. It is clearly referred to by 
Moses in the 15th chapter of Leviticus, where he lays down rules 
for the government of those who are affected with " a running issue 
out of the flesh." 

Among the Greeks and Eomans, gonorrhoea appears to have been 
less common than among the Hebrews ; still, unquestionable traces 
of it are found. Hippocrates describes five kinds of leucorrhoea, 
in addition to discharges dependent upon inflammation of the womb, 
which are mentioned separately. Herodotus states that "the 
Scythians made an irruption into Palestine and pillaged the temple 
of Yenus Urania. The angry Goddess sent upon them and their 
posterity the woman's disease, which is characterized by a running 
from the penis. Those attacked by it are looked upon as accursed." 
Celsus was also acquainted with balanitis and gonorrhoea ; the lat- 
ter dependent, as he supposed, upon an ulcer within the urethra ; 
and Cicero says that "incontinence gives rise to dysuria, in the 
same manner that high living causes diarrhoea." 

At subsequent periods, this disease, and, in many instances, its 
complications of swelled testicle and cystitis, were described with 
more or less detail by Mesue in 904 ; by Halli Abbas, one of the 
Persian magi, who followed the doctrines of Zoroaster and wrote in 
980 ; by Khazis, a learned Arabian physician, born in Chorosana 
in 852 ; by Albucasa, another Arabian of the eleventh century ; by 
Constantine of Carthage ; by Michael Scott in 1214 ; by Gariopon- 
tus of Salerno; by Eogerius, John Gaddesden of England (com- 
mencement of fourteenth century) ; John de Concoregio, John 
Arculanus, Guy de Chauliac, Valescus de Tarento, John Ardern, 
settled at London in 1371 ; and by many others. 1 Since the close 
of the fifteenth century, when the study of venereal diseases re- 
ceived new impulse from the irruption of syphilis into Europe, it 
is hardly necessary to state that every medical writer has been 
familiar with the existence of gonorrhoea. 

1 Chabalier, op. cit. 



INTRODUCTION. 19 

The history of the chancroid is essentially the same. Ulcers of 
the genital organs and suppurating buboes are described by nearly 
all the Greek, Latin, and Arabian writers on medicine. Hippocrates 
gives very minute directions for the treatment of abscesses in the 
groin, dependent upon ulcerations of the womb and of the genitals, 
Celsus is still more explicit, and clearly describes the simple, pha- 
gedenic, serpiginous, and gangrenous chancres, which are recognized 
at the present day. It would be difficult, for instance, to draw up 
a more faithful description of the phagedenic chancre than the fol- 
lowing : " Ulcus latius atque altius serpit solet etiam inter - 

dum ad nervos ulcus descendere ; profluitque pituita multa, sanies 
tenuis malique odoris, non coacta, et aquae similis in qua caro lota 
est ; doloresque is locus et punctiones habet." He also alludes to 
the danger of destruction of the prepuce when the ulcer is com- 
plicated with phymosis, and, under such circumstances, advises 
circumcision. Many other names might be quoted, but it is unne- 
cessary to adduce farther evidence upon this subject, since it is 
generally admitted that ulcers of the genital organs dependent upon 
contagion in sexual intercourse, have been known from a very re- 
mote antiquity. The only point in dispute relates to their nature. 

It is maintained by some authors, and especially by Cazenave, 
that they were true infecting chancres, and not chancroids, as I have 
here assumed ; and they have been supposed to furnish evidence of 
the existence of syphilis in Europe prior to the close of the fifteenth 
century. This idea is inadmissible for several reasons. One 
argument against it is the frequency of suppurating buboes with 
which these ulcers are said to have been attended ; since in the 
great majority of infecting chancres the inguinal ganglia which 
become indurated remain entirely passive ; while the chancroid, on 
the contrary, is frequently accompanied by an inflammatory bubo 
terminating in suppuration. This consideration, however, will 
have no weight with those who do not allow, in cases of primary 
sores, any prognostic value to suppuration of the inguinal ganglia ; 
but we can well afford to waive it and base our argument upon 
the fact that there is no record in history of the existence of 
general symptoms prior to the year 1494 ; that the ulcer of the 
genitals known to the ancients was always a local affection, and 
never followed by constitutional manifestations at a distance from 
the point of contagion; that repeated outbreaks of the disease 
when once apparently cured did not occur ; that hereditary syphilis 



20 INTRODUCTION". 

was unknown ; ] and finally, that the physicians who lived at the 
close of the fifteenth century, and who were perfectly familiar with 
the ulcers in question, were struck with horror and amazement at 
the appearance at this time of a disease which is now known to 
have been syphilis; confessed that they had never seen its like 
before, and that they were ignorant of its nature and treatment ; 
and in their treatises upon venereal for nearly thirty years after- 
wards, described this and the former disease in separate and distinct 
chapters, thus showing that they did not entertain the least idea of 
their identity. 

According to the most reliable contemporary authors, syphilis 
first appeared in Italy in the latter part of the year 1494, about 
the time that Charles VIII., King of France, at the head of a large 
army, entered that country for the purpose of taking possession of 
the kingdom of Naples to which he laid claim by right of inherit- 
ance. In this expedition, which was at first favored by the 
Neapolitans themselves, Charles left Eome on his way to Naples 
Jan. 28, and was received in the latter city Feb. 21, 1495. 2 The 
Neapolitans soon became restive under the yoke of their new 
master, and, assisted by the forces of Ferdinand of Aragon, under 
the leadership of Gronsalva of Cordova, the great captain, endea- 
vored to expel the French from Italy. 

Now, although the new disease probably had no necessary con- 
nection with the events just mentioned, yet the latter doubtless 
favored the extension and exacerbation of the former through the 
license and debauch attending large bodies of troops, and subse- 
quently led to mutual recrimination between the natives and the 
invaders respecting the origin of the malady ; the French calling 
it "Mai de Naples," because it was to them unknown before the 
Neapolitan expedition, and the Italians ascribing its origin to the 
French, and calling it the " French disease." 

It is often asserted that the subsequent extension of syphilis was 
due to its conveyance to their homes after the close of the war by 
the troops which had been collected upon Italian soil. This could 
not, however, have been the sole, nor even the chief mode of its 
transmission ; since the French, on their return from Naples, fought 
the battle of Fornovo, July 6, 1495, 3 and a decree of Emperor 

1 Syphilis in infants at the breast is first mentioned by (raspard Torello (1498). 

2 Guicciardini, liber i. cap. iv. 
8 Ibid., liber ii. cap. iv. 



INTRODUCTION. 21 

Maximilian I., "Contra Blasphemos," promulgated at the Diet of 
Worms, Aug. 7, of the same year, includes among the evils sent as 
a punishment against the prevailing vice of blasphemy, " praasertim 
novus ille et gravissimus hominum morbus, nostris diebus exortus, 
quern vulgo Malum Francicum vocant, post hominum memoriam 
inauditus, sseve grassatur," 1 thus showing that syphilis had already 
spread so widely in Germany as to attract general attention about 
the time that the French left Italy. 

Joseph Grunbeck, a German physician, writing in 1496, also 
describes the disease as it appeared in his own person, evidently at 
a considerable period prior to the date of his work. This author 
states, as quoted by Chabalier, that he was a happy man until this 
new pestilence found its way into Germany ; but that one pleasant 
day while walking in the fields, he found himself attacked with it ; 
"et primam venenosam sagittam in glandem Priapi ista foetidas 
deflxit, quae ex vulnere tumefacta, utrisque manibus vix compre- 
hendi potuisset." Sad and dejected he returned home, undecided 
whether he should make known his condition to his friends ; but 
the change in his countenance, his silence and despondency, made 
them suspect that some misfortune had occurred to him, and he 
was obliged at last to confess that he was attacked by the French 
disease, and to exhibit the evidences of it in his person. His 
dearest friends at once turned their backs upon him, and fled as if 
they had seen an enemy's sword suspended over their heads. 
Grunbeck's sadness was increased, and, retiring into solitude, he 
gave himself up to gloomy thoughts upon the vanity of earthly 
things and the ingratitude and perfidy of men. Meanwhile his 
disease extended, and a "thousand" ulcers appeared upon his penis 
and testicles and "vomited forth" bloody matter. After suffering 
in this manner for four months, he placed himself under the care of 
a celebrated empiric, who healed his sores by the application of a 
powder which gave him much pain. The disease disappeared from 
the penis, but soon returned upon the skin, where it assumed the 
form of tubercles. " Pestifera qualitas ex hoc suppurato et arcto 
loco retrocessit, atque in multis aliis verrucas passim in cutis super- 
ficiem elisit." The skill of the most celebrated physicians was 
unable to dissipate these new symptoms. Temporary relief was 
obtained from frictions with an ointment containing mercury, which 

1 Goldast. Const. Imp. II., 110. 



22 INTRODUCTION". 

was recommended by a charlatan, but several relapses subsequently 
occurred. 

The testimony of other authors also concurs in showing that 
syphilis rapidly extended in the course of a few years over the greater 
part of Europe, and pervaded every rank of society. As stated by 
John Lemaire, a poet of that period : — 

II n' espargnoit ne couronne ne crosse. 

A large amount of evidence is adduced by Bassereau and Chaba- 
lier in support of the fact already mentioned that syphilis was en- 
tirely unknown prior to the year 1494. Its connection with sexual 
intercourse was not at first recognized, and many attributed it to 
the evil influences of the stars ; and although a few endeavored to 
assimilate it to certain diseases of ancient times, as, for instance, to 
the "asaphati" of the Persians, the mentagra which prevailed at 
Eome under Tiberius, to psoriasis, elephantiasis, and lepra, yet the 
greater portion of the writers of that period declared that it was 
entirely new in the world's history, and all confessed that, so far as 
their own experience went, they had never seen anything like it. 

For instance, Philip Beroald, who died in 1505, says that he can 
neither affirm nor deny the truth of the supposition that it has pre- 
viously existed; all that he knows with certainty is that this 
"French disease, characterized by enormous prominent spots, by 
pustules giving the face and body a hideous aspect, sometimes 
painless, at other times causing the most excruciating suffering in 
the joints, and depriving the patient of rest and sleep at night, slowly 
consumes the body ; that it can be cured by no remedy ; that it was 
unknown to his ancestors ; that whatever others may name it, he 
desires to call it morbum pestiferum diuturnum ; that he prays, Dii, 
prohibite minas! Dii, talem avertite pestem! May this disease, 
more destructive than any pestilence, depart and return to the gulf 
of hell whence it came." 

James Cataneus de Lacu-Marcino, a Genoese, in his treatise de 
Morho Gallico, written in 1505, states that in the year 1494, under 
the pontificate of Alexander VI., and during the invasion of Naples 
by Charles YIIL, King of France, there appeared in Italy a terrible 
disease, which was never before known in any age ; which was new 
to the whole world ; which did not resemble the asaphati nor any 
other serpiginous and fetid ulcer, and which could not be regarded 
as epidemic ; but which spreading over the world was due to the 






INTRODUCTION. 23 

vengeance of God, who desires to punish fornication and adultery, 
which, though forbidden by law, are practised by men who live 
like wild beasts. 1 The testimony of many other writers is equally 
conclusive. 

The contagious ulcers of the genitals which were known prior to 
the latter part of the fifteenth century, were called " caries," " caroli," 
and "taroli," and the first of these terms was afterwards applied to the 
new disease, which, however, was distinguished as the " caries gal- 
lica." Moreover, in the works of Marcellus Cumanus, Alexander 
Benedictus, Leonicenus, Gaspar Torella, John de Vigo, and other 
authors who wrote within thirty years after the appearance of 
syphilis, these two affections were described in separate chapters 
with many of the distinguishing features that are recognized at the 
present day. Thus, John de Vigo mentions the induration of those 
ulcers which are followed by constitutional symptoms : " Cum cal- 
lositate eas circumdante ;" and none of the writers of this early 
period, when speaking of the French disease, make any allusion to 
suppurating buboes, which are described apart and referred to the 
" caries non gallica" known in ancient times. An exceedingly ac- 
curate description is also given of the cutaneous eruptions, the 
nocturnal pains, the bony tumors, and other general symptoms of 
syphilis ; and notice is taken of the fact that a cure is in most cases 
only temporary, and that the disease often returns. Moreover, the 
early writers on syphilis believed in the contagiousness of constitu- 
tional symptoms, and even of the blood of infected persons, which 
has recently been demonstrated by actual experiment. 

None of the theories which have been advanced to account for 
the appearance of syphilis in Europe near the close of the fifteenth 
century, rest upon sufficient data to entitle them to full credence. 
We cannot suppose that it was of the nature of an epidemic and due 
to atmospheric influences, since it is expressly stated by those who 
witnessed its advent that it did not suddenly affect large numbers 
of persons of all ages, but spread from one to another, chiefly at- 
tacking the middle-aged (the very class most exposed in sexual 
intercourse), and sparing old men and infants, and the inhabitants 
of cloisters, and that it advanced from Italy as a centre, and occupied 
several years in extending to the more remote countries of Europe. 
Moreover, our present knowledge of the disease enables us to state 

1 Chabaliek, op. cit., p. 87. 



24 INTRODUCTION". 

with confidence that it never appears except as the result of con- 
tagion. 

The theory which has met with the most favor, refers the origin 
of syphilis to America, whence Columbus returning from his first 
voyage, landed at Barcelona, in Spain, in 1493, only a year before 
the appearance of the disease in Italy. According to Chabalier, it 
was stated by John Baptist Fulgosus, Doge of Yenice, as early 
as 1509, that a new disease, communicated only by coitus and 
first affecting the genital organs, had broken out in Spain, and had 
thence been transported to Italy, and also that it came into Spain 
from Africa : " Quae pestis primo ex Hispania in Italiam allata, ad 
Hispanos ex ^Ethiopia, brevi totum terrarum orbem comprehendit." 
The idea that syphilis was brought to Europe from America by the 
sailors under Columbus, was first advanced by Leonard Schmans in 
1518, Ulrich von Hutten in 1519, and Fracastori in 1521, with 
what evidence I shall proceed to show. 

There can be no doubt that syphilis existed in the colony founded 
by Columbus during his second voyage, but whether indigenous to 
the West Indies, or brought there by the Spaniards, is unknown. 
Washington Irving, in his Life and Voyages of Columbus, 1 says, 
when speaking of the colony at Isabella : " Many of the Spaniards 
suffered also under the torments of a disease hitherto unknown 
among them, the scourge, as was supposed, of their licentious inter- 
course with the Indian females ; but the origin of which, whether 
American or European, has been a subject of great dispute." Cha- 
balier also adds the following testimony : — 

Peter Martyr, Governor of Castile in 1492, states in a work 2 
written in 1500 : " They have in this island (Hayti) a peculiar 
disease, characterized by large pustules occupying the body and 
eating into the extremities, because they are too much addicted to 
luxury. This disease is contracted by cohabitation with men and 
women who are already infected." 

Francisco Lopez de Gromare, almoner of Fernando Cortez, states 
that nearly all the Indians were affected with syphilis : " Los de 
aquesta isla Espannola son tudos bubosas, i como los Espannoles 
dormian con las Indias." 

Eodericus Diacius Insulanus, who was physician at Barcelona at 
the time syphilis made its appearance, is confident that it was brought 

1 Vol. i., book vi., chap. xi. 

8 De navigatione et terris de novo repertis. 



INTRODUCTION. 25 

to that city in 1493 by Columbus ; that the companions of Columbus 
ascribed their disease to the privations and fatigue of the voyage ; 
and that at Barcelona they infected the entire city, whence the 
disease was transported to Naples. When Charles VIII. arrived in 
Italy the following year, the opposing forces included a number of 
Spaniards affected with the disease, with regard to the nature of 
which they were ignorant, and which they attributed to atmospheric 
influences. 

Laying aside all American partialities, I have thus endeavored to 
give an impartial statement of the evidence upon this subject; 
which, as the reader will observe, contains no statement from those 
who took part in the discovery of the new world, that they found 
syphilis there on their arrival. Its existence in the Indies during 
the second voyage of Columbus may readily be explained by its 
transportation thither by the Europeans, who may be supposed to 
have been quite willing to ascribe their disease to the natives. It 
is unnecessary, however, to enter into a farther discussion of this 
point, since I think I can assert with truth that those authors of the 
present day who have paid the most attention to this subject, regard 
the testimony in favor of the supposed American origin of syphilis 
as far from conclusive. 

The views that were entertained by those who witnessed the first 
appearance of syphilis in Europe, and which in many respects 
coincided to a remarkable degree with those which have recently 
been advanced in the middle of the nineteenth century, gradually 
lost their hold upon succeeding generations, and were followed by 
the utmost confusion of ideas respecting this subject. A most 
admirable history of this " age of confusion in venereal," as it has 
been called, is given by Bassereau, which should be read by every 
one who would understand the origin of those errors from which the 
medical mind has but recently commenced to free itself, and which 
yet find advocates among the profession. In justice to M. Bassereau, 
Who was the first to discover the evidence afforded by history in 
favor of the duality of the chancrous virus, I prefer to give the 
following extended extract from his remarks instead of a mere 
abridgment ; and this course is the more desirable since the original 
discoverer is but little known in this country, and others have had 
the credit of his labors. 1 

1 In conversations with American physicians, I have been surprised to find many 
who were entirely unacquainted with the name of M. Bassereau, and who attri- 



26 INTRODUCTION. 

" In the first part of the 16th century, a tendency to confound 
the various venereal diseases appeared. Thus, George Vella (A. D. 
1508), attributed them all to the same cause. The following is his 
line of argument : It is conceded, he says, that before the existence 
of the French disease, certain women communicated to men by 
coitus, ulcers which were never followed by that assemblage of 
symptoms which make up the new disease. But it is also certain 
that the latter commences with ulcers upon the genitals, which are 
contracted in the same manner from diseased women, and have the 
same objective symptoms (quoad sensum visus) as the ulcers of the 
penis anterior to the appearance of the French disease, so that the 
most skilful physicians cannot distinguish them. If, then, these 
ulcers are contracted in the same manner, have the same aspect, 
and cannot be distinguished from each other, why not refer them 
to the same principle ? Vella admits that it may be objected that 
a new effect presupposes a new cause, and that since the French 
disease was never observed before, it must be produced by some 
other cause than the one to which we refer the contagious ulcers of 
the genitals which have been known in all ages. In answer to 
this objection, he replies, that the causes of disease may at times 
assume a greater activity, just as we see pestilential fevers produce 
greater ravages at certain periods than at others, while yet the 
cause remains the same. 

"It may also be objected, he says, that the necessity of new 
remedies indicates a difference in the nature of the disease. He 
replies, that it is indeed true that the remedies employed to cure 
the ulcers anterior to the French disease, are insufficient for the 
new disease, but that the means which are efficacious in the latter, 
will also cure the former. This is equivalent to saying that the 
remedy of a severe disease is generally sufficient for a light disease, 
while the remedy of a light disease is not always the one required 
for a grave disease. 

" George Vella, therefore, very clearly establishes the fact, which 
we have seen to be apparent in the writings of Alexander Bene- 
dictus, Marcellus Cumanus, and John de Vigo, viz., the existence 
of contagious ulcers, the effects of which were confined to the geni- 
tal organs, before the year 1495, and the appearance about this 

buted the honor of producing the first proof in favor of the duality of the chancrous 
virus to M. Clerc, whose views, differing from Bassereau's and now known to be 
incorrect, were published two years later than those of the last mentioned author. 



INTRODUCTION. 27 

period of a new disease, which commenced upon the private parts 
in the form of ulcers, which were soon followed by general cutaneous 
eruptions, pains in the joints, etc. In addition to this — and the idea 
is entirely his own — he endeavors to show that these two affections 
are dependent upon the same cause. 

" It was not irrational nor inconsistent with pathology in Telia, 
to consider the new ulcers of the genitals which affect the whole 
system, as of the same nature as the local ulcers which were known 
in all ages, and to suppose that the latter had suddenly assumed an 
unusual activity under the influence of some peculiar state of the 
constitution. Unfortunately, his theory rests only upon two very 
contestable facts : 1. The identity in their mode of transmission. 2. 
Their striking resemblance and the impossibility of distinguishing 
between them. But it is evident that the same mode of communica- 
tion in two diseases does not prove their nature to be the same ; and 
Vella's supposed similarity in the appearance of all chancres had 
already been refuted by his predecessors. In fact, most preceding 
authors had agreed in their statements, that the ulcer which was 
followed by general symptoms, could be recognized by its livid 
aspect and its hard and indurated base ; and this ulcer appeared to 
them so different from the ordinary chancre, that in their works 
upon venereal, they described it in separate books or chapters. 

" The writers on syphilis, whose testimony I have adduced in 
opposition to Telia's, did not say that the ulcer of the French dis- 
ease always presented decided special symptoms ; nor do I myself 
attempt to sustain this opinion. In one of the preceding sections, I 
have shown that the characteristic induration was wanting in a 
number of primary sores, which were followed by syphilitic ery- 
thema. 

" The doctrines professed by George Telia induced neglect of the 
study of the special symptoms of chancres, and greatly contributed 
to introduce confusion with regard to these ulcers. This confusion, 
however, was especially the work of those physicians, who had 
commenced the practice of their art subsequent to the year 1495, 
and who, therefore, were unable to compare the new disease with 
the venereal affections which had prevailed from time immemorial, 
before the close of the 15th century. In following the change 
which took place, we find that the first step was to make no dis- 
tinction in their writings between the old and new chancre, and to 
include in their descriptions of syphilis certain complications which 



28 INTRODUCTION". 

belong almost exclusively to the ancient variety of ulcer. Thus, 
Nicholas Massa (1532), the author of a celebrated treatise on the 
French disease, includes among the unequivocal symptoms of this 
affection, suppurating buboes, which almost exclusively belong to 
the chancre of the ancients. Yet it had not escaped the observing 
mind of Massa, that chancres followed by suppurating buboes are 
rarely succeeded by cutaneous eruptions and other general symp- 
toms; so that, after speaking of these buboes as a symptom of true 
syphilis, he is obliged to confess that patients who have them are 
generally exempt from the eruptions and pains which constitute the 
French disease. ' Et sequuntur apostemata inguinum quse si sup- 
purantur removent aegritudinem.' Matthiolus (1535) also includes 
suppurating buboes among the symptoms of the French disease. 
Antony Lecoq (A. D. 1540) speaks of them in the same terms as 
Nicholas Massa ; whilst Fracastorius (A. D. 1530) and Sebastian 
Montius, both witnesses of the appearance and progress of syphilis, 
continue to describe this disease (the former in a special treatise, 
the latter in his ' Dialexeon' published in 1537, when he was eighty 
years old), as was done by Marcellus Cumanus, Benedictus, Leoni- 
cenus, Graspar Torella, and many others, without including suppu- 
rating buboes among its symptoms. 

" As the chancre of the ancients, and its attendant suppurating 
bubo, began to be included among the symptoms of syphilis, trea- 
tises on surgery ceased to contain those special chapters in which 
contagious ulcers of the genital organs and inguinal abscesses had 
heretofore been described. Discharges from the urethra were also 
included among the symptoms of syphilis, and still farther modified 
the tableau. Finally, in the descriptions given of the French dis- 
ease, not only were symptoms inserted which were completely 
foreign to syphilis, but the regular course of this affection was 
entirely forgotten. 

11 This confusion was rendered complete by Anthony Musa Bras- 
savolus. This physician, who was a laborious student rather than 
a sagacious observer, seems to have made it an object of his treatise 
upon the French disease, published in 1551, to collect together all 
the errors of the writers upon syphilis of this period, and to add 
others of his own invention. Not only did he include all venereal 
affections under the head of syphilis, but, as described by him, this 
affection lost its characteristic physiognomy, and was a mere collec- 
tion of symptoms succeeding each other without order or regularity. 



INTRODUCTION. 29 

According to this author, buboes may appear before chancres upon 
the penis ; syphilis may commence indifferently as an exostosis, an 
eruption upon the skin, pains in the bones, or falling out of the hair 
and teeth. He goes so far as to admit eight primary symptoms, 
which he calls the simple forms of the disease, and which by their 
union in various ways may give rise to an infinite variety of com- 
binations, which he terms the compound forms of syphilis, and 
limits to two hundred and thirty -four in number. 

" Brassavolus, it is true, did not escape severe criticism. Gabriel 
Fallopius, his pupil, called his views 'futile inventions,' and Joseph 
Scaliger did not hesitate to say that Brassavolus was the echo of the 
vulgar herd of physicians of his day : ' Cymbalum ineptse medico- 
rum plebis.' But. error, especially when sanctioned by a great 
name, is a source of great danger, since many minds are wont to 
accept the opinions of others without criticism, and to study books 
rather than nature. The doctrines of Brassavolus, therefore, were 
not without influence ; and if we except the excellent treatises of 
Fernel and Leonard Botal, most of the works upon syphilis that 
appeared during the two following centuries, were more or less 
tainted with these doctrines. Even at the present day, since the 
publication of the writings of Hunter, and his annotators, we have 
still a school of Brassavolus. To be convinced of this fact, it is 
only necessary to read what has been published on syphilis since 
the commencement of the nineteenth century. 

"Yet, after the time of Brassavolus, the syphilitic chancre, on 
account of the induration of its base, was still considered by some 
writers as distinct from the ulcer which is not succeeded by general 
symptoms. Thus Fallopius (A. D. 1555) devotes the eighty -first 
chapter of his treatise upon the French disease to the purpose of 
showing that there are several species of chancres; that there is a 
great difference between the 'caries gallica' and the 'caries non gal- 
lica;' that the former precedes the French disease, and has no con- 
nection with the latter, which is described in the writings of ancient 
and also in those of modern physicians prior to the year 1495. 

"After Fallopius, Antonius Fracantianus (1564), a celebrated 
professor at Bologna, also says that the chancre which precedes 
constitutional syphilis, may always be distinguished with ease from 
the one the action of which is local. 'Siquis carie amciatur norunt 
non tantum chirurgi, sed et inepti tonsores, num caries ilia gallica 



30 INTRODUCTION. 

sit nec ne ; hoc vero non nisi ab exustione et sorditie, quae lividc 
vel nigro colore, et ex callositate innotescit.' 

"Again, Nicholas de Blegny, in 1673, speaks of the indurated 
chancre; but, unlike preceding authors, does not regard it as a 
distinct species, but as an indication that the general symptoms of 
syphilis are likely to follow ; and, in this respect, his views agree 
with those of Eicord at the present day." [As the reader is 
probably aware, Eicord has since adopted the distinct nature of 
the two species of primary sore.] 

"After the venereal affections which had been known in ancient 
times had thus been confounded with the disease which appeared 
at the close of the fifteenth century, and after the natural history of 
syphilis had been completely lost sight of under the supposition 
that the variations in the symptoms produced for the most part by 
treatment were really modifications in the course of the disease, 
an incident occurred which is worthy of attention, and does not 
require comment. Physicians perceived that the recent descriptions 
of syphilis did not coincide with those given by the authors who 
had witnessed the earliest appearance of the disease in Europe ; 
and as it was impossible to suspect that the earlier writers had 
omitted gonorrhoea and suppurating buboes, which were now re- 
garded as the most frequent and positive indications of syphilis, 
they supposed that the type of the disease had changed, and that 
since its first appearance new symptoms had been added. Thus 
Brassavolus says that gonorrhoea was not a symptom of the French 
disease until about 1520 ; and Gabriel Fallopius, writing in 1555, 
that the same disease appeared fifteen years before as a new symp- 
tom of syphilis, the protean nature of which is thus apparent. 
'Ultimum signum est gonorrhoea gallica, signum incipientis morbi 
quae nobis indicat istius Protaei naturam.' Yet Alexander Bene- 
dictus had written more than fifty years before, that gonorrhoea, 
which had been known in every age, had become as it were 
epidemic since the appearance of the French disease; still, the 
assertion of Brassavolus and Fallopius prevailed, and, repeated by 
most succeeding writers on syphilis, became, so to speak, a classic 
dogma. 

"Buboes were also considered of more recent date than the other 
symptoms of syphilis, and their origin was referred to the year 
1514, because at that time they were first included among the 
manifestations of the French disease by Nicholas Massa. 



INTRODUCTION. 31 

"These pretended changes in the disease were the foundation of 
the fabulous ' periods' or ' epochs' of syphilis, invented by Astruc 
(A. D. 1736), and composed of various elements, among which are 
found : 1. The symptoms of those venereal affections which existed 
prior to syphilis and were successively annexed to it ; 2. Certain 
symptoms belonging to syphilis, as the late form of alopecia and 
exostoses, which generally appear several years after infection, and 
which consequently did not figure in the early descriptions of the 
French disease which were written before the close of the fifteenth 
century ; 3. Certain symptoms, as pustular eruptions, which were 
very prominent on account of their frequency and intensity for 
some years, but which were afterwards supplanted in a measure by 
other manifestations of the disease which at an early period were 
quite uncommon, but which subsequently acquired a great degree 
of importance; I refer to gummy tumors, which, according to 
Fracastorius, were very frequent about the year 1540. 

"In all these 'periods' of Astruc, only one fact is supported by 
medical tradition, and that is the gradual diminution in the intensity 
of syphilitic symptoms, which is attested by many reliable authors, 
and which is evident to any one who compares the frightful de- 
scriptions of this disease which were written in the latter part of 
the fifteenth century, with those which appeared twenty years 
later, or with others which have been published in our own day. 

"The modifications of the doctrines professed by those who 
witnessed the first appearance of syphilis in Europe, could not fail 
to affect the treatment of venereal diseases. Before the year 1495, 
ulcers of the genital organs, the suppurating buboes dependent 
upon them, the various forms of vegetations and discharges from 
the urethra, were considered as purely local affections, and treated 
by means of local remedies. As soon as the French disease 
appeared, the insufficiency of all topical applications in the treat- 
ment of the new disease was manifest ; but human ingenuity, never 
more fertile in resources than under circumstances of great necessity, 
soon discovered in mercury a powerful modifier of the new com- 
plaint. For several years this remedy was employed in the form 
of frictions, and only in case the patient had broken out with an 
eruption following a sore upon the genital organs; but it soon 
became the custom to resort to mercurial inunction immediately 
after contagion and during the existence of the primary sore, with 
a view of preventing the appearance of general symptoms. This 



32 INTRODUCTION. 

practice was first recommended by James Cataneus, who thought 
that the same remedy which cured the pustular eruption would 
also prevent it. 'Hsec enim onctio, absque dubio, tale destruit 
virus : quod enim unam sanat aegritudinem, ab eadem prseservat.' 

" This wise precept, to employ mercurial medication during the 
existence of the primary sore for the purpose of preventing a general 
eruption, soon gave rise to the most serious errors ; for, about the 
time that it was given, physicians began to ignore the distinction 
between the two species of ulcers, and were consequently led to 
treat them all indiscriminately with mercury. This injurious, not 
to say barbarous practice, has been continued to the present day, 
and has led to an exaggerated estimate of the powers of mercury, 
which, for three centuries, has been given to a multitude of patients, 
who have been supposed to be preserved through its influence from 
symptoms of which they stood in no danger. 

" Hence we may explain the success of all those modes of treat- 
ment which charlatans have endeavored to substitute for mercury 
when given during the existence of supposed primary symptoms, 
as a prophylactic against secondary manifestations ; since, if the same 
treatment, no matter what, be applied without distinction to patients 
with gonorrhoea, chancres, and buboes, there will always be a large 
proportion who will escape farther trouble, for the simple reason 
that their symptoms do not belong to the disease which first ap- 
peared in the fifteenth century, and are, therefore, incapable of 
infecting the general system." 

Having thus followed medical belief in its gradual divergence 
from the faith of the early writers upon syphilis until it merged 
into the greatest confusion of ideas relative to venereal diseases, it 
would be interesting to trace its return during the present century 
to the original starting-point, and, as is believed, to the true doc- 
trine. But an account of the labors of Hunter, Bell, Carmichael, 
Babington, Bassereau, Diday, Kollet, Langlebert, Clerc, Fournier, 
Acton, Victor de Meric, and, above all, of that master-spirit, Philip 
Eicord, to whom alone we owe so much, and the influence of whose 
example and teaching is evident in nearly all that has of late years 
been accomplished by others, would, if at all commensurate with 
the subject, require more room than our limited space can afford, 
and can only be given in such fragments as the occasion may 
require, in the following pages. 

Probably no cause contributed more powerfully to the production 



INTRODUCTION. . 33 

and continuance clnring three centuries of confused ideas respecting 
venereal diseases than the fact that they are usually transmitted in 
the same manner, viz., by sexual intercourse. As already seen, 
this was a strong argument with George Yella in favor of their 
dependence upon one and the same poison; and it may well be 
doubted if it has entirely lost its weight at the present time. And 
yet it requires but a moment's thought to be convinced that this is 
the shallowest possible foundation upon which to build a theory as 
to the nature of any disease ; for if identity in the mode of commu- 
nication proves identity of species, we must regard all those affec- 
tions which are conveyed through the medium of the air, or, in 
other words, the whole tribe of epidemics, as constituting one 
disease; those which are communicated by contact, as the itch, 
favus, etc., another ; and so on, making as many species as there are 
ways of transmission. 

As Eollet has ably shown, 1 the communication of gonorrhoea, the 
chancroid, and the true chancre in the sexual act is merely an 
accidental circumstance, and due to the fact that these diseases are 
capable of affecting the genital organs which are brought into such 
frequent and intimate contact. The conditions during coitus are 
in the highest degree favorable for contagion to take place ; and all 
contagious diseases, the active principle of which is fixed and not 
volatile, which find their natural habitat in man, and which are 
capable of affecting the genital organs in the two sexes, are fre- 
quently transmitted in this manner. The only diseases of this 
latitude which fulfil these requirements are gonorrhoea, the chan- 
croid, and syphilis ; while " in those countries in which other con- 
tagious affections, as the yaws and radzyge, foreign to our own 
climate, exist, they also are communicated in sexual intercourse, 
and are, strictly speaking, venereal." Scarlet fever, variola, measles, 
and other contagious diseases dependent upon a volatile poison, are 
naturally transmitted by way of the respiratory organs. Hydro- 
phobia, glanders, vaccinia, etc., are not natural to man ; and those 
contagious diseases which depend upon the presence of a parasite, 
as the itch, favus, and herpes tonsurans, are incapable of affecting 
mucous surfaces. 2 

1 De la pluralite des maladies veneriennes, Graz. Med. de Lyon, No. 7, Apr. 1, 

1860. 

2 RoLLET, Op. Cit. 

3 



34 INTRODUCTION. 

This is not the only mode of transmission of venereal diseases, 
since gonorrhoeal inflammation is not unfrequently communicated 
from one eye to another through the medium of the conjunctival 
discharge conveyed upon towels and other articles in common use ; 
and the secretion of the soft chancre and of the lesions of true 
syphilis, whether primary or secondary, is contagious when properly 
applied, by whatever means, to any part of the body. In infants, 
the frequent and intimate contact of nursing takes the place of that 
during coitus, and the most common mode of transmission of vene- 
real diseases is through the medium of the breast ; while even in 
adults constitutional syphilis is not unfrequently contracted from a 
primary or secondary lesion situated upon the mucous membrane 
of the mouth, tongue, or fauces. 

Our review of the history of venereal diseases has incidentally 
furnished us with proof that gonorrhoea and syphilis are not de- 
pendent upon the same poison by showing that they have originated 
at different periods, the former being known in all ages, the latter 
only since the close of the fifteenth century ; but the chief evidence 
of the distinct nature of these affections, like that of all other dis- 
eases, is to be found in clinical observation. We infer that inter- 
mittent fever is different from hooping-cough, the smallpox from 
rheumatism, phthisis from the measles, etc., because the symptoms, 
course, termination and susceptibility to the action of remedies, in 
each, are different. And yet, in none of the diseases mentioned, is 
the difference greater than between gonorrhoea and syphilis; the 
former being characterized by the symptoms of catarrhal inflamma- 
tion common to mucous membranes, not infecting the general 
system, exposed to complications which are for the most part 
seated in organs which hold direct communication with the urethra 
through the medium of a mucous surface — as, for instance, the 
testicle, bladder and prostate, amenable to local treatment, and 
terminating in resolution and a complete restoration to health ; the 
latter disease commencing with an ulcer followed by a long cate- 
gory of general symptoms, its complications usually seated in the 
lymphatic system, mercury and iodine its chief remedies, its effect 
upon the constitution, if not permanent, at least of long duration. 

And let it not be objected to this argument, that the premises 
assume what it is attempted to prove. Nothing has been assumed, 
but a simple statement given of the results of clinical observation. 
The differences which I have mentioned characterize the two dis- 



INTRODUCTION. 35 

eases in the great majority of cases, as every one will admit ; and 
the general testimony afforded by the symptoms, course, and termi- 
nation is, in all diseases, considered sufficient to establish their 
distinctive character. In the exceptional cases, in which one dis- 
ease appears to run into another, we seek and are generally able to 
find an adequate explanation, although in some instances we fail ; 
but we do not, therefore, infer that the line of demarcation between 
them should be entirely effaced. 

Let any one follow out a series of cases of gonorrhoea from their 
commencement, assuring himself that the constitution is not already 
infected with syphilis from previous exposure, making a careful 
examination for the purpose of ascertaining that no chancre is 
present upon any part of the body, and keeping the patient under 
observation, in order to be sure that no primary sore is subsequently 
contracted, and it may safely be asserted that the investigation will 
satisfy any candid mind of the distinct nature of gonorrhoea. In 
all the reported cases, with scarcely an exception, which have ap- 
peared to favor a belief in the identity of gonorrhoea and syphilis, 
the mode of investigation has been exactly the reverse of the above. 
The patient has not been seen by the surgeon until general symp- 
toms have appeared, and the only knowledge of his previous history 
has been derived from his own lips. Now, such cases are entirely 
valueless, for the simple reason that a patient is an incompetent 
witness upon a subject with regard to which, unless a medical man, 
he is necessarily ignorant. He may state, with perfect honesty, that 
his only previous symptom has been an attack of gonorrhoea, and 
yet he may, without knowing it, have had a chancre within the 
urethra, or even upon the external surface of the genitals (since 
the superficial form which the infecting chancre most frequently 
assumes, may be attended by such slight symptoms as entirely to 
escape observation), or a primary sore may have been situated upon 
some remote part of the body, and, consequently, its character not 
have been suspected, and, in many instances, careful inquiry and 
examination will show that one of these suppositions is true. There 
are also other sources of error too numerous to dilate upon here, 
but which will receive due consideration hereafter. Now, with 
these facts before us, and even granting, in some cases of constitu- 
tional syphilis, apparently commencing with a discharge from the 
urethra without appreciable ulceration, that no plausible explana- 
tion can be discovered, which is the more probable ; that such ex- 



36 INTRODUCTION. 

planation really exists, or that nature in disease belies herself by 
contradicting in a few rare instances what she is constantly teach- 
ing in unmistakable terms in the overwhelming majority ? 

Eicord thought to find additional proof of the distinct nature of 
gonorrhoea and syphilis in artificial inoculation. He inoculated the 
discharge of the former upon the patient and the result was nega- 
tive ; the same experiment, performed, as he supposed, with the 
secretion of a chancre, was successful ; whence he concluded that 
artificial inoculation upon the person affected, would enable us to 
distinguish between the urethral discharge of gonorrhoea and that 
from a concealed chancre. He has since discovered that a true 
chancre is not auto-inoculable, and, consequently, that his successful 
inoculations upon the individuals from whom the matter was taken 
must have been performed with the virus of the chancroid. It fol- 
lows, therefore, in respect to capability of inoculation upon the 
patient himself, that the true chancre is precisely upon the same 
footing as gonorrhoea ; neither one nor the other is auto-inoculable ; 
and hence this test, at one time much insisted upon by Eicord, 
though not original with him, is proved fallacious. 

For all practical purposes, the idea that gonorrhoea is identical 
with syphilis is exploded ; for although, in some works upon vene- 
real, this error still retains the form and proportions which it as- 
sumed for three centuries, it is a corpse without life ; since, however, 
its friends may preach, it would be difficult to find one among them 
who puts his principles in practice, and treats gonorrhoea with mer- 
cury. Diday 1 has adduced the testimony of three of the Internes 
of the Hopital du Midi in proof of the fact that Yidal, one of the 
strongest advocates among recent writers of the syphilitic nature of 
gonorrhoea, invariably treated this disease as a simple inflammation 
without mercury. 

The distinct nature of the chancroid, like that of gonorrhoea, is 
supported by clinical observation and by history ; but the discus- 
sion of this subject must be deferred to the first chapter of the second 
part of this work, in which I shall attempt to show that the chan- 
croid and syphilis preserve their respective traits through any 
number of successive transmissions, from one person to another ; 
and, therefore, that the distinctive character of each may be said to 
rest upon the same evidence that is regarded as final in the classifi- 

1 Nouvelles doctrines sur la syphilis, p. 100. 



INTRODUCTION. 37 

cation of the animal and vegetable kingdoms, viz., perpetuity of 
species. 

I propose to divide the present work into two parts : The first 
devoted to gonorrhoea and its complications ; the second including, 
for the sake of convenience, and in accordance with common usage, 
both. the chancroid and its complications, and syphilis. 



PAET I. 

GONORRHEA AND ITS COMPLICATIONS. 



CHAPTER I. 

URETHRAL GONORRHOEA IN THE MALE. 

Peeliminaey Considekations. — By far the most frequent dis- 
ease originating in sexual intercourse, is an affection of certain 
mucous membranes, a prominent symptom of which is an increased 
secretion and discharge from the diseased surface. At various 
times and places, this disease has received different names, founded 
on the prevailing ideas of the nature of the secretion referred to. 
At an early period in the history of Venereal, the discharge was 
supposed to consist of semen, and hence the disease was called 
gonorrhoea, from yo^, sperm, and [>s«>, to flow; a name which is still 
in use among American and English writers, notwithstanding the 
incorrectness of the supposition in which it originated. 1 The French 
call the same affection " blennorrhagie," or a flow of mucus, a name 
which is also erroneous, since the discharge does not consist of 
mucus alone, but of a mixture of mucus and pus. In popular 
language it is termed " clap" by the English, and " chaude-pisse" 
by the French. 

The chief mucous membranes subject to gonorrhoea are those 
lining the genital organs in the two sexes, and the conjunctiva 
oculi. Gonorrhoea of the anus, mouth, nose, and external ear are, 
indeed, mentioned by authors, but the existence of all of them is 
more or less doubtful. Perhaps there is the least question in ad- 

1 Cockburne (The Symptoms, Nature, Cause, and Cure of Gonorrhoea, London, 
1715) first established the fact that gonorrhoea is not a flow of semen. 



40 URETHRAL GONORRHCEA IN THE MALE. 

mitting gonorrhoea of the anus and rectum, though it is said to be 
rare even in countries where unnatural practices are frequent ; but 
we can hardly admit under this head those cases in which the anus 
is simply excoriated by a discharge flowing from the urethra or 
vulva, without extension of the disease to the rectum. 

Eeported cases of gonorrhoea of the mouth, nose, and external 
ear are very few in number, and are all of them open to serious 
question ; as, for instance, the supposed case of gonorrhoea of the 
nose, reported by Mr. Edwards, 1 in which it is very doubtful 
whether the disease was of this origin and not a simple catarrhal 
affection. M. Diday relates some experiments which will serve to 
elucidate this point, though we are surprised, in reading them, that 
any surgeon should presume to make them, or any patient submit 
to them. M. Diday says : " Frequently (eight or ten times at least), 
for the purpose of experiment, I have moistened the end of my 
finger in the urethral discharge of patients with gonorrhoea, when 
the disease was in its most acute stage, applied it within the nostrils 
and rubbed it into the nasal mucous membrane, and there has 
never resulted the slightest degree of inflammation in the part." 2 

But when we recollect how frequently a disregard of cleanliness 
must cause the application of gonorrhoeal matter to the nostrils and 
lips, and how readily such applications excite inflammation of the 
ocular conjunctiva, the great rarity of suspected- cases of nasal and 
buccal gonorrhoea must convince us, without the necessity of such 
experiments as those above mentioned, that certain mucous mem- 
branes are more apt to contract gonorrhoea than others ; and in this 
we may find an analogy to an extraordinary fact which has recently 
excited much attention, viz., that all parts of the body are not 
equally susceptible of the two varieties of chancre ; the chancroid 
never being met with upon the head or face, although it may be 
implanted there by artificial inoculation. The reason of the 
preference of these diseases for certain localities escapes us, but 
they are not the only instances of the kind met with. 

The symptoms and the treatment of gonorrhoea vary according 
as the disease affects the male or female, and according also to the 
portion of mucous membrane, attacked; it will be convenient, 
therefore, to consider this affection under corresponding heads. 

1 London Lancet, Am. ed., June, 1857. 

2 Annuaire de la syphilis, annee 1858. 



SYMPTOMS. 41 



UEETHEAL GONOEEHCEA IN THE MALE. 

Men are more liable to contract gonorrhoea than women ; and of 
a given number of cases of this disease in the former, in a large 
proportion it is the urethra which is affected. Cases of urethral 
discharge in the male outnumber all other forms of gonorrhoea in 
the two sexes combined. The explanation of this fact will appear 
when we come to consider the causes and nature of gonorrhoea. 

Symptoms. — The symptoms of urethral gonorrhoea in the male 
first appear, as a general rule, between the second and fifth day 
after exposure ; though, in exceptional cases, as late as the seventh, 
tenth, or fourteenth clay ; but their occurrence after this time, as 
alleged by some authors, is, I believe, to be explained on the 
ground that the earliest manifestations of the disease have been 
overlooked. At first, the symptoms are very slight, consisting only 
of an uneasy or tickling sensation at the mouth of the canal, which, 
on examination, is found more florid than natural, and moistened 
with a small quantity of colorless and viscid fluid, which glues the 
lips of the meatus together. This moisture of the canal gradually 
increases in amount, until on pressure a drop may be made to 
appear at the orifice. At the same time it begins to lose its clear, 
watery appearance, and assumes a milky hue. Examined under 
the microscope, it is found to consist of mucus with the addition of 
pus-globules ; the number of the latter being proportioned to the 
depth of color of the discharge. Meanwhile, some smarting is felt 
by the patient in the anterior portion of the canal during the 
passage of the urine. 

Such are the symptoms of the early stage of gonorrhoea. The 
exciting cause of the disease has been applied to that portion of 
the canal which lies near the orifice of the meatus and which was 
chiefly exposed to contagion, and the ensuing inflammation is 
gradually lighted up in this part, and has not yet extended beyond 
that portion of the urethra known as the fossa navicularis. This 
early stage of gonorrhoea is often called "the stage of incubation," 
a name which is objectionable because the inflammatory process is 
doubtless set up at the time of the application of the exciting cause. 
Time is required for it to produce its full effect, and the earliest 
symptoms are but slowly and gradually ushered in. A more 



42 URETHRAL GONORRHCEA IN THE MALE. 

appropriate name is the first or preparatory stage. It is important to 
recollect the symptoms of this stage and the fact that the disease is 
as yet confined to the external portion of the urethra, since, as we 
shall see hereafter, a more rapid method of cure may now be 
resorted to than is admissible in the subsequent stages. 

The first stage of gonorrhoea usually lasts from two to four days. 
The symptoms gradually increase in intensity, until, in about a 
week after exposure, the second or inflammatory stage may be said 
to commence. If we examine the penis during this stage, we find 
the mucous membrane covering the glans, reddened and with an 
angry look. The whole extremity of the organ is swollen so that 
the prepuce fits more tightly than natural. In some cases the 
latter is puffed out by oedema in its cellular tissue, and phymosis 
may exist, rendering it impossible to uncover the glans. The 
inflammatory blush is especially marked in the neighborhood of 
the meatus, the lips of which are swollen so as to contract the 
calibre of the orifice. The discharge has now become copious, so 
much so in some instances as to drop from the meatus as the patient 
stands before you. It is thick, of a yellowish cream color, and not 
unfrequently tinged with green. This greenish hue, as in the 
sputa of pneumonia, is due to the admixture of blood-corpuscles, 
which may be sufficiently numerous to produce the characteristic 
color of blood. The penis generally, and especially upon the 
under surface over the course of the canal, is sensitive and tender 
on pressure. 

While passing his urine, the patient complains of intense pain, 
which is now not confined to the anterior part of the canal, but is 
felt in all that portion of the organ anterior to the scrotum, or is 
even more deeply seated. The severity of the suffering during the 
act is in some instances very great. The pain is compared to the 
sensation of a hot iron introduced within the canal, and the popular 
name, chaude-pisse, given to the disease by the French, is fully 
justified. This pain is excited in part by the irritation produced 
upon an abnormally sensitive membrane by the salts contained in 
the urine, but chiefly, I am inclined to think, by the distension of 
the contracted and sensitive canal by the passage of the stream. 
Hence, during the act, the patient involuntarily relaxes the abdomi- 
nal walls, forces the air from his lungs, and keeps the diaphragm 
elevated, in order to diminish the pressure upon the bladder and 
lessen the size and force of the stream of urine. In consequence 






SYMPTOMS. 43 

also of the urethra being contracted and more or less obstructed by 
the discharge, the stream is forked or otherwise irregular. 

Another source of suffering in this stage of gonorrhoea is the 
nocturnal erections, which are apt to come on after the patient is 
warm in bed. The genital organs are in a highly sensitive con- 
dition, and are readily excited by lascivious dreams, the contact of 
the bedclothes, or a distended bladder ; or, independently of such 
exciting cause, they assume a state of erection which even in health 
is more apt to occur during sleep. When thus excited, it will often 
be found that the penis is bent in the form of an arc with its 
concavity downward. This condition is known as chordee. Its 
explanation is very simple. The urethra, the chief seat of the 
inflammation, runs along the under surface of the penis. Plastic 
lymph is effused around this canal, gluing the tissues together and 
rendering this portion of the penis less extensible than the remain- 
ing portion composed of the corpora cavernosa. Hence, in a state 
of erection, the corpus spongiosum surrounding the urethra, not 
being able to yield to the distension, acts like the string of a bow, 
and chordee is produced. The stretching of the parts thus ad- 
hering together excites pain, which is often very severe. The 
sufferer, awaking from sleep, instinctively grasps the penis in his 
hand, and bends it in a still smaller curve, so as to remove the 
strain from the under surface and thus ease the pain. It not unfre- 
quently happens that during one of these attacks of chordee, the 
mucous membrane of the urethra becomes lacerated, and hemor- 
rhage takes place from the canal. In this way nature may produce 
local depletion, and, if the flow be not excessive, the effect is often 
beneficial. 

The above explanation of the mechanism of chordee is the one 
usually received, though it is proper to state that it is rejected by 
Mr. Milton, who believes that chordee is due to spasm of the mus- 
cular fibres, which Mr. Kolliker and Mr. Hancock have shown to 
exist around the whole course of the urethra. 1 I am not convinced 
that the generally received opinion should thus be laid aside, though 
it is highly probable that spasmodic muscular action plays some 
part in the production of the frequent erections and chordee which 
take place in gonorrhoea. 

During the inflammatory stage of gonorrhoea abscesses sometimes 

1 Milton on Gonorrhoea, p. 75. 



44 URETHRAL GONORRHOEA IN THE MALE. 

form in the cellular tissue covering the urethra ; either anteriorly 
to the scrotum, or in the perineum ; and may attain a very con- 
siderable size. If left to themselves, they are liable to break 
internally within the canal and give rise to urinary abscess and 
fistula. 

It is also chiefly during the second stage of gonorrhoea that buboes 
are met with, if they occur at all ; for they are rare compared with 
the number of patients afflicted with this disease. They are at once 
recognized by the physician and patient by the enlargement and 
tenderness of one or more glands in the groin, occasioning consider- 
able pain and uneasiness in walking and standing. Buboes attend- 
ant upon gonorrhoea, uncomplicated with chancre, are sympathetic 
buboes;, of which a fuller description will be given hereafter, when 
speaking of buboes in general. They may generally be made to 
disappear in a few days by keeping the patient quiet and producing 
a little counter-irritation by painting the skin over them daily with 
tincture of iodine. It is only in scrofulous subjects, or in conse- 
quence of violence, excessive fatigue or general depressing influ- 
ences, that they ever exhibit a tendency to suppurate. I have 
known of one instance of a man suffering from gonorrhoea, who 
after exposure to great hardship upon a wreck, had a suppurating 
bubo that confined him to his bed for six months. 

Inflammation of the lymphatic vessels running along the dorsum 
of the penis is still another complication of the acute stage of gonor- 
rhoea, and one which is also met with in connection with simple 
chancres. It is to be carefully distinguished, as we shall see here- 
after, from the induration of these vessels which often attends an 
indurated chancre. " It occupies the same vessels and the same 
situation, and presents the same forms as the latter; but is distin- 
guished from it in several ways : 1. By its feel, which is like that 
of an hypertrophied cord, elastic but not cartilaginous. 2. By the 
fact that the cellular tissue uniting the vessels generally participates 
in the inflammation, and thus binds together in a large cord the 
dorsal vein, the lymphatics and the artery, rendering it difficult to 
distinguish the inflamed lymphatics from the bloodvessels. 3. By 
the pain, generally severe, which it excites, and by the swelling and 
redness visible over the course of the inflamed vessels, caused by 
the extension of the inflammation to the skin." 1 This inflammation 

1 Basseeeau : " Affections de la peau symptomatiques de la syphilis," p. 160. 



SYMPTOMS. 45 

of the lymphatics on the dorsum of the penis sometimes gives rise 
to chordee, with the concavity of the arc looking upward. 

The second stage of gonorrhoea, which we have now described, is 
variable in its duration in different subjects. As a general rule, it 
lasts from one to three weeks, being influenced by the constitution 
of the individual, his mode of life and the number of his previous 
attacks. It is succeeded by the third stage or stage of decline. 
This final stage of acute gonorrhoea is marked by no peculiar symp- 
toms, and is characterized only by the disappearance of the more 
acute symptoms and a gradual return to a condition of health. The 
discharge runs through the same phases, in an inverse order, which 
it did at the outset of the attack. It gradually becomes less and 
less purulent, and finally is almost wholly mucous, before completely 
disappearing. . 

Perhaps the most valuable indication of the ushering in of this 
stage of gonorrhoea is the marked diminution or entire cessation of 
the pain in passing water. The painful erections and chordee may 
continue after the acute inflammation has subsided, since it takes 
time for the plastic matter effused around the urethra to be ab- 
sorbed. 

We have reason to believe that in the course of an attack of 
gonorrhoea, the disease gradually extends from the outer to the 
deeper portions of the canal, and it is in this latter situation that it 
is prone to lurk for an indefinite period. After the discharge has 
lasted for several weeks, we may evacuate the whole of the spongy 
portion by pressure from behind forward in front of the scrotum, 
and then, when no further discharge can be made to appear, we can 
still produce it by the exercise of similar pressure on the perineum. 
In some instances, the inflammation extends to the mucous mem- 
brane of the bladder. 

The duration of the final stage of gonorrhoea is, as a general rule, 
longer than either of the preceding. It may be cut short by treat- 
ment, but, if left to itself, commonly lasts for weeks or even months. 
Gonorrhoea is a disease which, independently of treatment, rarely 
terminates in less than three months. 

Thus far I have said nothing of the reaction of this disease upon, 
the general system. This varies greatly in different individuals and 
in different attacks in the same person. In some rare cases there 
is considerable febrile excitement during the inflammatory stage, 
marked by the usual symptoms of headache, dry skin, full pulse, 



46 URETHRAL GONORRHOEA IN THE MALE. 

furred tongue, etc. As a general rule, however, there is but little 
constitutional disturbance, and after the acute symptoms have passed, 
the invariable tendency of the disease is to depress the general 
health. This fact should be remembered in the treatment. 

A first attack of gonorrhoea is usually more acute than subsequent 
ones; the latter often being subacute or chronic from the first. 
They are also more difficult to be influenced by remedies, and show 
a decided tendency to run into gleet. 

Cases of gonorrhoea have been reported, in which it has been said 
there was no discharge whatever — all the other symptoms of gonor- 
rhoea being present, and the disease following impure coitus. These 
have been called cases of dry gonorrhoea. I doubt whether there 
be a total absence of all secretion in these cases throughout their 
whole course, but can readily conceive of an inflammation of the 
mucous membrane of the urethra, resembling that of erysipelas upon 
the skin, in which the secretion is for a time but slight, and incapa- 
ble of detection except by a careful examination of the urine. As 
the inflammation subsides, however, I should expect to find distinct 
traces of a discharge. We have analogous symptoms occasionally 
in inflammations of the pituitary membrane of the nose. Two cases 
of this variety of gonorrhoea are reported by Dr. Beadle in the New 
York Journal of Medicine and Surgery, for October, 1840. 

Causes and Nature of Gonorrhoea. — Every one is aware that 
urethral gonorrhoea in the male often proceeds from direct conta- 
gion, or, in other words, from intercourse with a woman affected 
with the same disease. But there is another mode of origin, ad- 
mitted by nearly every writer, as of at least occasional occurrence, 
but with regard to the frequency of which some difference of 
opinion has been expressed. I refer to gonorrhoea originating in 
coitus just before, after, or during the menstrual period, or with a 
woman suffering from leucorrhoea, and, in a few instances, when 
nothing whatever abnormal can be discovered in the female genital 
organs, and the disease in the male can only be attributed to the 
irritant character of the vaginal or uterine secretions. 

I have been convinced, by a somewhat extended observation, 
that gonorrhoea originating in this mode is of very frequent occur- 
rence. Of one thing I am absolutely certain, that gonorrhoea in the 
male may proceed from intercourse with a woman with whom 
coitus has for months, or even years, been practised with safety, 



CAUSES AND NATURE OF GONORRHOEA. 47 

and this, too, without any change in the condition of her genital 
organs, perceptible upon the most minute examination with the 
speculum. I am constantly meeting with cases in which one or 
more men have cohabited with impunity with a woman both before 
and after the time when she has occasioned gonorrhoea in another 
person ; or, less frequently, in which the same man, after visiting a 
woman for a long period with safety, is attacked with gonorrhoea 
without any disease appearing in her, and after recovery resumes 
his intercourse with her and experiences no farther trouble. The 
frequency of such cases leaves no doubt in my mind, that gonor- 
rhoea is often due to accidental causes, and not to direct contagion. 

In many of the instances referred to, the woman is suffering from 
a frequent combination of symptoms met with in practice, viz., 
general debility, engorgement of the cervix uteri, and more or less 
leucorrhoea ; but her previous history, and the impunity with which 
her favors have been bestowed for a long period, preclude the idea 
that her discharge is the remains of a previous attack of gonorrhoea 
to which it owes its contagious property. Moreover, such an ex- 
planation fails to cover other instances, in which there is no appear- 
ance whatever of leucorrhoea, and the genital organs, so far as we 
can discover, are in a state of perfect health ; although intercourse 
about the time of the menstrual period has given rise to gonorrhoea 
in the male. 

An attempt is sometimes made to evade the issue of this ques- 
tion, by asserting that in the cases referred to, the disease has been 
contracted from another source than the one alleged, and the pro- 
verbial mendacity of venereal patients is appealed to in support of 
this assumption. Argument is of course useless with any one 
assuming this ground ; but to a candid mind, the opinion of such 
men as Eicord, Diday, and others, who fully sustain the position 
above assumed, and who are certainly not ignorant of the sources 
of error surrounding the etiology of venereal diseases, is sufficient 
to carry great weight, and lead to an impartial investigation of facts 
which can be followed but by one conclusion. For my own part, 
I desire to state that while pursuing the investigation which has led 
me to believe in the frequency of gonorrhoea, independent of con- 
tagion, I have not entertained a single case in which the moral 
grounds of certainty have not been irresistible ; and that a number 
of my patients have been medical men, and intimate acquaintances, 
whose sins against morality were fully known to me, who could 



4-8 URETHRAL GONORRH03A IN THE MALE. 

therefore have had no motive for concealment, and with whom mis- 
take or deceit has been either in the highest degree improbable, or, 
in repeated instances, impossible. Moreover, it is a mistake to sup- 
pose that in investigations of this nature we are entirely at the 
mercy of the patient's honor and truthfulness, since to one practis- 
ing in a large city there are a thousand sources of circumstantial 
evidence and remarkable coincidences in the testimony of persons 
wholly unknown to each other, which in many cases preclude all 
possibility of error. 

The greatest obstacle to the admission of gonorrhoea independent 
of contagion appears to be the rarity of urethritis in married men 
compared with the frequency of leucorrhceal discharges in their 
wives. As proved by unquestionable cases occurring in my own 
practice and in that of my medical friends, husbands do not always 
escape. That they are not more frequently affected is sufficiently 
explained by the immunity conferred against all simple irritants 
by constant and repeated exposure, whereby " acclimation" — to use 
a term adopted by the French — is acquired. The same fact is 
observed when neither the church nor the state has sanctioned 
marital relations ; since it is not generally the habitual attendant 
upon a kept mistress affected with leucorrhoea who suffers, but 
some fresh comer who shares her favors for the first time. 

Most cases of gonorrhoea from leucorrhoea or the menstrual fluid 
present no characteristic symptoms by which they can be distin- 
guished from those originating in contagion. The contrary is 
frequently asserted, and it is said that the former class may be 
recognized by the mildness of the symptoms, the short duration of 
the disease, and the absence of contagious properties. I am familiar 
with the slight urethral discharge unattended by symptoms of acute 
inflammation, and disappearing spontaneously in a few days, which 
sometimes follows intercourse with women affected with leucorrhoea ; 
but such instances are far less frequent than those in which the 
disease is equally as persistent and as exposed to complications as 
any case of gonorrhoea from contagion. Some of the most obstinate 
cases of urethritis I have ever met with have been of leucorrhceal 
origin, and have terminated in gleet of many months' duration. 

Those who maintain the non-contagious character of urethral 
discharges of leucorrhceal origin have failed to adduce the slightest 
proof in favor of their assumption, and it may safely be asserted 
that none of them would venture to make a practical application 



CAUSES AND NATUEE OF GONOEEHCEA. 49 

of their principles. The contagious character of the leucorrhoeal 
secretion is already proved by the existence of the disease in the 
male ; why should not the same property be continued another, 
still another, and any number of removes from its origin ? This 
supposition is sustained by analogy, since no fact is better established 
than, that catarrhal conjunctivitis may be communicated from one 
person to another until all the members of a family, school, or 
asylum have become affected. At our public institutions for 
diseases of the eye such instances are very common and the plry- 
sicians of our children's asylums are well aware of the difficulty of 
eradicating muco-purulent conjunctivitis which has once sprung up 
among the inmates. At an orphan asylum, under the charge of 
my friend, Dr. Learning, this disease was introduced by a single 
child, brought from Randall's Island, and spread to twenty-two 
others before it could be arrested. Again, the leucorrhcea of 
pregnancy is sufficient to give rise to ophthalmia neonatorum: 
would any one, presuming upon its leucorrhoeal origin, dare to 
apply a drop from the infant's eyes to his own ? Several instances 
are recorded in which physicians have lost the sight of an eye 
with which the discharge of ophthalmia neonatorum has inadvert- 
ently been brought in contact. 

The views which I have here advocated relative to the frequency 
of gonorrhoea independent of contagion, are by no means novel, 
and are entertained by many of our most eminent authorities, 
especially among the French, who possess unequalled advantages 
for investigating the etiology of venereal diseases. The importance 
of the subject will fully justify me in making the following quota- 
tions from other authors. 

Eicord says : "Ifive investigate with the greatest care the exciting 
causes of gonorrhoea — and I am now speaking of the most charac- 
teristic cases of the disease — we cannot help admitting that a 
gonorrhceal virus is absent in the majority of cases. ISTothing is 
more common than to find women who have occasioned gonorrhoea 
unsurpassed in intensity and persistency, and attended by the most 
serious complications, and who are yet only affected with uterine 
catarrh which is sometimes hardly purulent. In many cases, inter- 
course during the menstrual period appears to be the only cause of 
the disease ; while, in a large number, we can discover nothing, 
unless perhaps errors in diet, fatigue, excessive sexual congress, 
4 



50 URETHRAL GONORRHCEA IN THE MALE. 

the use of certain drinks, as beer, or of certain articles of food, as 
asparagus. Hence the frequent belief of patients, which is very 
often correct, that they have contracted their gonorrhoea from a 
perfectly sound woman. 

" I am most assuredly familiar with all the sources of error in 
such investigations, and I will presume to say that no one is more 
guarded than I am against the various forms of deceit which are 
strown in the path of the observer ; yet I confidently maintain the 
following proposition : Gonorrhoea often arises from intercourse ivith 
women who themselves have not the disease. Any one who studies 
gonorrhoea without preconceived notions, is forced to admit that it 
often originates from the same causes that give rise to inflammation 
of other mucous membranes." 1 

The "preconceived notions" that Eicord here speaks of, have 
been the greatest obstacle to the admission of the truth in ques- 
tion. To a surgeon making up his mind beforehand that every 
patient utters a falsehood who says that he has contracted his 
gonorrhoea from a woman in whom no evidences of disease can be 
found, any amount of proof is valueless. 

Diday, in speaking of the prophylaxis of venereal diseases, says : 
" A man should never forget that gonorrhoea may be contracted 
from any woman ; and I say any woman, and not any 'prostitute, for 
I do not except from this uncivil remark, any member of the gen- 
tler sex. No matter how great her cleanliness, her apparent 
health, her supposed or real virtue, or even her virginity, or how 
recently she has been examined, a woman may, from some cause 
or other, have the whites — often of a very innocent character, as 
from metritis, chlorosis, dysmenorrhoea, catarrhal inflammation, or 
as a result of confinement, and also, on the other hand, from a 
gonorrhoea which she has contracted ; and from the very fact that 
she has a discharge — no matter what its origin — she is liable to give a 
discharge to a many 2 

Fournier arrives at the same result from an investigation rela- 
tive to the classes of women from whom gonorrhoea is derived. It 
appears from his statistics that gonorrhoea was contracted from in- 
tercourse with 

1 Lettres sur la Syphilis, 2d ed., p. 29. 

2 Nouvelles Doctrines sur la Syphilis, p. 515. The Italics are in the original. 



CAUSES AND NATURE OF GONORRHOEA. 



51 





Cases 


Women of the town . 


12 


Clandestine prostitutes .... 


44 


Kept women, actresses, etc 


. 138 


Working girls ...... 


. 126 


Domestics ....... 


41 


Married women ...... 


26 



Total 



387 



Founder adds : " This result is easily explained, and might even 
have been predicted. In fact, gonorrhoea is, I think, much less 
frequently contracted from contagion than from excessive coitus, 
repeated or prolonged sexual congress, or peculiar excitement dur- 
ing the act ; and in most cases of intercourse with public women, 
all these causes are absent, and intercourse is generally very short, 
without much excitement, and not frequently repeated." 1 

Again, Mr. Henry Thompson says : " It is a fact too well estab- 
lished to render it necessary to adduce evidence respecting it here, 
that urethritis in the male is sometimes caused by contact with the 
other sex, from discharges which are not venereal in their origin." 2 

Finally, from many other writers whose testimony is equally 
strong in favor of the leucorrhceal and menstrual origin of gonor- 
rhoea in many cases, I will quote the remarks of Mr. Skey : — 

" I cannot entertain a doubt that a very considerable proportion 
of cases of gonorrhoea are not the product of a specific poison. The 
opinions I entertain on this subject are not the product of mere 
speculation, and still less of a desire to differ with other and more 
experienced authorities. They are deduced from, what appeared 
to my judgment, positive facts, and those by no means few or far 
between. I may venture to say it is notorious that leucorrhoea will 
produce gonorrhoeal discharge; and if a poison be essential to 
gonorrhoea, whence comes it? Leucorrhoea is not supposed to 
contain the elements of gonorrhoeal poison. Again, gonorrhoea is 
by no means an infrequent result from intercourse about the period 
of menstruation ; and it also follows intercourse with women under 
circumstances of mechanical violence." 3 

The importance of the truth laid beforo the reader in the above 
remarks and quotations, whenever a physician in the exercise of his 



1 De la Contagion Syphilitique, p. 118. 

2 Stricture of the Urethra, p. 120. 

3 Lectures on the Venereal Disease, London Medical Gazette, vol. xxiii. (1838-9) 
p. 439. 



52 URETHRAL GONORRHCEA IN THE MALE. 

profession incurs the fearful responsibility of passing judgment 
upon the virtue of a woman, and thus affecting her reputation and 
happiness (and often that of many others with whom she is con- 
nected) for life, cannot be overrated. In all such cases, the accused 
should receive the benefit of any doubt which may exist ; and the 
physician who withholds it from her out of a morbid fear that he 
may be imposed upon, 1 and thus runs the risk of convicting an in- 
nocent person, is unworthy of his calling. His province is to decide 
from the symptoms taken in connection with the known facts of the 
case, and unless these are sufficient to establish guilt beyond the 
shadow of a doubt, humanity demands at least a verdict of " not 
proven." The following cases will illustrate this point : — 

Case 1. A gentleman of the city, six weeks after marriage, applied to 
his physician to be treated for gonorrhoea, which he solemnly declared he 
had contracted from his wife, and his known probity was such as to render 
his statement in the highest degree probable. Under the supposition 
that his disease could only have arisen from contagion, he had already ac- 
cused his wife of unchastity, her friends had been informed of the charge, 
and a separation and action for divorce were imminent. His physician 
examined the wife, whom he found perfectly healthy, and ascertained, on 
farther inquiry, that the disease in the husband was due to the continu- 
ance of coitus during a menstrual period. 

Case 2. The following case is reported in a work entitled " Sur la non- 
existence de la maladie venerienne," which was published in Paris in 
1826:— 

A young man became attached to a young female friend, " a peine sortie 
de l'enfance," and married her after some years of mutual attachment. 
Some months after this " hymen fortune ! " the young man was compelled 
to take a journey to some distance, and, while travelling, he experienced 
pain in making water, and shortly perceived a discharge from the urethra. 
On arriving at a town, he consulted an eminent surgeon, who assured him 
he had a gonorrhoea. " Mais, monsieur, je suis nouvellement marie," and 
he assured the learned surgeon, that he had never known any woman but 
his wife from the hour of his birth. "Comment," repond le chirurgien, 
en souriant, " vous voudrez me cacher la cause de votre mal : de quel pays 
etes-vous ? Yos jeunes gens rougiroient; je vous certifie, monsieur, que 
vous avez une belle et bonne chaude-pisse." The youth continued to 

1 In a discussion upon the origin of gonorrhoea independent of contagion, which 
I once held with the writer of a work on venereal, the final argument of my op- 
ponent was, "I do not like to feel that I am imposed upon by patients." 



CAUSES AND NATUKE OF GONORRHOEA. 53 

protest his innocence. Some days after the testicle swelled. The sur- 
geon now assured him that if his wife were virtuous, he must have had 
" une affaire" with other women, and that the pox remained in his blood 
from that period. Between the two alternatives of his own or his wife's 
purity, of course he could not entertain a doubt. He wrote to her an in- 
dignant and passionate letter, and then blew out his brains. The un- 
fortunate woman submitted to an examination, which proved her free from 
disease, never uttered another word — shortly miscarried, and died. So 
much for the honor of our noble profession ! * 

Case 3. A few years since, in one of the New England States, a clergy- 
man came very near being deposed from the ministry, and convicted of 
adultery, on the testimony of his physician, that a urethral discharge for 
which he had treated him could only have arisen from impure inter- 
course ! 

Other causes, in addition to those already mentioned, may give 
rise to urethral gonorrhoea in the male. Thus, unquestionable in- 
stances are reported in which a gouty or rheumatic diathesis with- 
out exposure in sexual intercourse has occasioned a discharge from 
the urethra. 

Eicord relates a remarkable case of tubercular deposit in dif- 
ferent portions of the urethra of a strumous subject with sympto- 
matic urethral discharge ; 2 and a scrofulous diathesis is generally 
a strong predisposing, if not an active cause of inflammation of the 
urethra as well as other mucous canals. 

Mr. Harrison reports the case of a medical practitioner who 
suffered from a puriform discharge, heat and pain along the course 
of the urethra, attended with frequent micturition, chorclee, and 
sympathetic fever, after eating largely of asparagus. 3 

Among other causes of urethritis are free indulgence in fermented 
liquors, terebinthinate medicines, paraplegia inducing changes in 
the urine, the use of bougies, stricture, masturbation, prolonged 
excitement of the genitals, vegetations within the urethra, ascarides 
in the rectum, dentition, epidemic influences, etc. 

M. Latour, editor of the Union Medicate, vouches for the truth of 
the following history : A physician, thirty years of age, had been 
continent for more than six weeks, when he passed an entire day 
in the presence of a woman whose virtue he vainly attempted to 

1 Quoted by Mr. Sket, loc. cit. 

2 Bulletin de l'Acad. de Med., vol. xv. p. 565. 

3 London Lancet, Am. ed., Jan., 1860. 



54 URETHRAL GONOREHffiA IN THE MALE. 

overcome, and who resisted all his approaches. From ten o'clock 
in the morning until seven in the evening, his genital organs were 
in a constant state of excitement. Three days afterwards he was 
seized with a very severe attack of gonorrhoea, which lasted for 
forty days. 

A chancre within the nrethra is attended with more or less thin 
and often bloody discharge, which will be more particularly de- 
scribed in a subsequent portion of this work under the head of 
concealed chancre. I will merely remark at present that inoculation 
of the secretion upon the person affected cannot determine the 
presence of a primary sore, unless it be a chancroid, since the 
infecting chancre is not auto-inoculable. 

Again, urethral discharges are sometimes due to changes in the 
mucous membrane lining the canal, induced by infection of the 
constitution with the syphilitic virus. In several instances I have 
observed a muco-purulent discharge coinciding with the first out- 
break or a relapse of secondary symptoms, and so long after the 
last sexual act that it could not be attributed to the ordinary 
causes of gonorrhoea. Bassereau speaks of similar cases. 1 There 
is no more frequent seat of early constitutional manifestations than 
the mucous membranes in general; and in the cases referred to 
changes probably take place in the urethral walls similar to the 
erythema, mucous patches, and superficial ulcerations which are 
found within the buccal and nasal cavities. These cases are very 
rare, and can only be distinguished from ordinary gonorrhoea by 
the previous history and coexisting symptoms of the patient. For 
instance, if there has been no exposure for a long period, and 
especially if secondary symptoms have recently made their appear- 
ance upon other mucous membranes, the urethral discharge is 
probably symptomatic of the constitutional diathesis. Since the 
secretions of secondary lesions are now known to be contagious, 
the discharge in these cases is doubtless so, also; but it is not 
susceptible of inoculation upon the person from whom it is derived 
nor upon any other affected with the syphilitic diathesis, and, if 
communicated to a healthy individual under the requisite conditions, 
will give rise to an infecting chancre. 

The inferences from what has now been said of the etiology of 
gonorrhoea relative to its nature, are so obvious that they require 
little more than mere mention. If in a large proportion of cases 

1 Affections Syphilitiques de la Peau, p. 356. 



TREATMENT. 55 

the disease can be traced to no other cause than leucorrhcea, the 
menstrual fluid, or, in less frequent instances, to excessive coitus, 
intercourse under circumstances of special excitement, inattention 
to cleanliness, the abuse of stimulants, etc., and if, when thus ori- 
ginating it is undistinguishable either by its symptoms, course, 
complications, or termination from the same affection due to con- 
tagion, it is evident that it should be ranked among the ordinary 
catarrhal inflammations of mucous membranes, or, in other words, 
that it is a simple urethritis, the connection of which with sexual 
intercourse is a merely accidental, or at all events, not a necessary 
circumstance. 

But — it may be asserted — the possibility of contagion proves 
the presence of a poison. Granted : but it does not follow that it 
is a specific poison, or one incapable of being produced by simple 
inflammation. Such a conclusion would be contrary to the facts 
adduced in the preceding pages, and, moreover, is not required by 
the analogy of inflammations of other mucous membranes ; since, 
in muco-purulent conjunctivitis — the true analogue of gonorrhoea — 
we have precisely the same order of events, viz., inflammation 
originating in simple causes, and giving rise to a secretion which is 
contagious and capable of transmission through an indefinite series 
of individuals. The discharge from the two mucous surfaces just 
mentioned would even appear to be transferable, since that from 
the urethra applied to the eye gives rise to purulent ophthalmia, 
the secretion of which, if we may rely upon a few experiments by 
Thiry, of Brussels, will, when brought in contact with the lining 
membrane of the urethra, produce urethritis. In the first chapter 
of the second part of the present work I shall take occasion to 
institute a comparison between the poisons of gonorrhoea, the soft 
and the hard chancre. 

I have no space to discuss the untenable theory of a "granular 
virus" of gonorrhoea advanced by M. Thiry, according to which, 
the presence of granulations upon the mucous membrane is neces- 
sary to render the discharge contagious. 1 

Treatment. — The treatment of gonorrhoea must be adapted to 
the general condition of the patient, and especially to the stage of 

' M. Thiry's views have been published in a series of lectures in the Presse 
Med. de Bruxelles, and are also advocated by Guyomar, These de Paris, 1858 
(No. 282). 



56 URETHKAL GONORRHOEA IN THE MALE. 

his disease. In the great majority of cases met with in practice, 
acute inflammatory symptoms have already set in at the time the 
patient first applies to the surgeon ; but in those exceptional cases 
which are seen at an early period, we may often succeed in cutting 
short the disease by means of the treatment termed abortive. 

Abortive Treatment of the First Stage. — During the first few days 
after exposure, varying in number from one to five in different 
cases, before the symptoms have become acute, when the discharge 
is but slight and chiefly mucous, and while as yet there is no severe 
scalding in passing water, we may resort to caustic injections with 
a view of exciting artificial inflammation which will tend to subside 
in a few days, and supplanting the existing morbid action which is 
liable to continue for an indefinite period and is exposed to various 
complications. This is known as the " substitutive," or more com- 
monly as the "abortive treatment" of gonorrhoea. This method 
has been inordinately praised and as violently attacked ; its true 
merit is probably to be found between these two extremes. It is 
certainly liable to be greatly abused, and, if so, is both unsuccessful 
and capable of producing the most unpleasant consequences ; but 
when limited to the early stage of gonorrhoea and used with proper 
caution, it is a highly valuable method of treatment, unattended 
with danger, and undeserving the censure sometimes cast upon it. 

In employing the abortive treatment, there are several points 
which it is important to recollect : 1. The disease, in the stage to 
which this treatment is applicable, is limited to the anterior portion 
of the urethra, known as the fossa navicularis, or extends but a 
short distance beyond it; it is not necessary, therefore, that the 
injection should reach the deeper portions of the canal. 2. For 
the treatment to be successful, the whole diseased surface should 
receive a thorough application of the injection, for if any portion 
remain untouched, it will secrete matter that will again light up 
the disease. 3. When once a sufficient degree of artificial inflam- 
mation is excited, the caustic has accomplished all that can be 
expected of it, and should be suspended. 

Since a solution of nitrate of silver, which is commonly used in 
the abortive treatment, is readily decomposed by contact with 
metallic substances, metal syringes should be avoided. Glass sy- 
ringes, if well made, answer every purpose; but as found in the 
shops, they are apt to be unequal in calibre in different parts of 
the cylinder, the wadding of the piston contracts in drying, and a 



TREATMENT. 57 

portion of the fluid fails to be thrown out, as is seen by its overflow 
when the syringe is filled a second time. For these reasons, I never 
advise a patient to purchase a glass syringe, knowing that it will 
probably give him much annoyance, and perhaps prevent his de- 
riving benefit from treatment. Fortunately, we have a very excel- 
lent substitute in the hard-rubber syringes which can be obtained 
at the druggists'. 1 

The solution of nitrate of silver, in the abortive treatment of 
gonorrhoea, may be of considerable strength, when only one injec- 
tion will be required ; or it may be weak, and in that case should 
be repeated at short intervals until the effect produced be deemed 
sufficient. I much prefer the latter course, especially with patients 
who apply to me for the first time, since it enables me to graduate 
the effect according to the susceptibility of the urethra, which varies 
in different persons. The following is the formula for the weak 
form of injection : — 

Rl. Argenti nitratis crystalli gr. j-iss. 

Aquse destillatse 5jyj. 
M. 

"With this, as with all injections in gonorrhoea, it is essential to 
success that the surgeon should administer the injections to his 
patients, or see, by actual observation, that they know how to use 
them. Yerbal directions cannot be relied upon. 

The patient should be made to pass his water immediately be- 
fore injecting, or, better still, a quarter of an hour before. We 
wish to clear the urethra of matter, and to have the bladder empty, 
so that the injection may have some time to act before it is washed 
away by another passage of the urine, and yet a short interval 

1 An excellent series of urethral syringes is manufactured by the American Hard 
Rubber Company. In these instruments, the diameter of the cylinder is in all 
parts the same ; the piston works with great accuracy ; the material is not acted 
upon by ordinary medicinal agents, and the different sizes and forms of the in- 
strument are adapted to the various purposes for which it is required. The size 
most generally applicable to the treatment of gonorrhoea is called "No. 1, B." It 
holds half an ounce, which is not too much for injections in the latter stages of the 
disease ; if used in the abortive treatment of the first stage, it should be only half 
filled. "No. 1 " holds two drachms, and is well adapted for the abortive treatment. 
The "Urethral Syringe with extra long pipe," is, in fact, a syringe united to a 
catheter, and is adapted for injections of the deeper portions of the canal or the 
bladder. The catheter portion may be bent to any curve desired, by first heating 
it over a spirit-lamp. 



58 URETHRAL GONORRHOEA IN THE MALE. 

between the last act of micturition and the injection is advisable, 
in order that as much of the urine as possible may have drained 
from the canal and little be left to decompose the nitrate of silver. 
The prepuce should now be fully retracted, and the glans penis 
exposed. The latter should be wiped dry, so as to afford a firm 
hold to the thumb and forefinger of the left hand, applied to its 
opposite sides, and firmly compressing it around the point of the 
syringe, introduced to its full extent within the meatus. If this 
pressure be properly made, not a drop of the solution will be lost, 
as the piston of the syringe is slowly forced down by the forefinger 
of the right hand holding the instrument, and the whole contents 
will be discharged into the canal. The syringe should now be 
withdrawn, and the fluid still retained for a few seconds by con- 
tinuing the compression of the glans. When the injection is allowed 
to escape, it will be found to be of a milky- white color. This is 
due to the partial decomposition of the contained salt by the remains 
of the urine and the muco-pus in the canal. As this decomposition 
has prevented the application of the injection in its full strength to 
the urethral walls, a second syringeful should be thrown in, and 
retained for two or three minutes. During this time, a finger of 
the disengaged hand should be run along the under surface of the 
penis from behind forwards, so as to distend the portion of the canal 
occupied by the injection, and insure the thorough application of 
the fluid to the whole mucous surface. 

This description of the method of using the syringe is, in the 
main, applicable to all the injections which may be required in the 
course of a gonorrhoea ; but we are now speaking of the abortive 
treatment, by means of weak injections of nitrate of silver. We 
will suppose that this first injection has been administered by the 
surgeon, who, at the same time, has explained the various steps of 
the operation to the patient. The directions with regard to diet, 
etc., that will presently be mentioned in speaking of the second 
stage, should now be given ; the patient should be ordered to 
repeat the injection every three hours, and, for the present, it is 
best that he should be seen by the surgeon twice a day. It is also 
well at this time to prescribe an active purge. 

The first effect of the caustic injections is manifested in a few 
hours ; the discharge becomes copious and purulent, and consider- 
able scalding is felt in passing water. In the course of twenty -four 
or thirty-six hours, however, the discharge grows thin and watery, 



TREATMENT. 59 

and, very likely, is tinged with blood. It is now time to stop the 
injection and omit all medication for a few days, nntil we see how 
much good has been accomplished. If the treatment meets with 
its usual success the discharge will gradually diminish, and finally 
disappear in from three to five days. Sometimes, however, after 
growing less, it again increases, showing a tendency to relapse. In 
that case, I usually advise weak injections of sulphate of zinc, as 
recommended in the third stage of the disease. Some surgeons 
prefer to resume the caustic injections in the same manner as at 
first, if, after a week has elapsed, any traces of the discharge 
remain. 

The chief objection to this modification of the abortive treatment 
is, that it is necessary to leave the administration of most of the 
injections to the patient, who may be prevented by ignorance, or 
the requirements of his occupation, from using them as thoroughly 
or as often as is necessary. If we have reason to fear this, we may 
resort to a stronger solution, and inject it once for all, with our own 
hands. It was this method of employing the abortive treatment 
that was recommended by Debeney of France, and Carmichael of 
England, by whom this treatment was first introduced to the 
profession. The same method is also still employed and highly 
recommended by many surgeons, and especially by M. Diday of 
Lyon. The strong injection should not contain less than ten 
grains of the nitrate of silver to the ounce of distilled water, and 
more than fifteen grains are objectionable, unless with patients who 
have been under treatment before, and in whom the urethra has 
been found to be quite insensible. 

^l. Argenti nitratis crystalli gr. x-xv. 

Aquse destillatse §j. 
M. 

The mode of using this injection is identical with that already 
described. Two small syringefuls should be thrown in ; the first 
to clear the urethra of urine and muco-pus, the second to exercise 
a curative effect ; and the surgeon should feel that the success of 
the treatment depends, in a great measure, on the thoroughness of 
its application. As an additional precaution against the fluid 
extending further back than is necessary, the patient may compress 
the penis anteriorly to the scrotum, while the surgeon is adminis- 
tering the injection. 

There is still another mode of employing a strong solution of 



60 URETHRAL GONORRHOEA IN" THE MALE. 

nitrate of silver, by means of an instrument introduced by Dr. F. 
Campbell Stewart, of this city, and called by bis name. This 
instrument consists of a straight canula inclosing a sponge, which 
can be made to protrude from its extremity. The sponge is first 
soaked in a solution of nitrate of silver, and concealed within the 
canula. The instrument is then introduced for about two inches 
within the urethra, when the canula is to be partially withdrawn ; 
the sponge is thus exposed to the contact of the urethral walls, in 
which position it is to be allowed to remain for a minute or two, 
and then withdrawn by slowly twisting it on its long axis. By 
the use of Dr. Stewart's instrument, the extent of the application 
can be limited at will, and it is perhaps owing to this fact that we 
can employ with safety a much stronger solution than when using 
a syringe. I have thus applied a solution of twenty, and even 
thirty grains to the ounce, without exciting an undue amount of 
inflammation, or other unpleasant symptoms. Care should be 
taken that the instrument be of sufficient size. Some of those 
found in the shops are too small, not exceeding a No. 7 bougie in 
diameter. I have had one manufactured for my own use of the 
size of No. 10. 

I cannot leave this subject of the abortive treatment of gonor- 
rhoea, without again expressly stating that I recommend it only in 
the first stage of the disease, and not after acute inflammatory symp- 
toms have set in, or the patient suffers from scalding in passing 
water. Taking the usual run of cases as met with in practice, 
probably not more than one out of ten is seen at a sufficiently 
early period to admit of the abortive treatment. Its employment 
in the acute stage, as recommended by its inventors, is generally 
unsuccessful, and dangerous and even fatal results have been 
known to ensue. Prudent practitioners have limited the use of 
caustic injections to the early stage of gonorrhoea, except in some 
instances in the decline of the disease ; but, in the latter case, the 
mode of injecting must be modified so that the fluid may reach 
the deeper portions of the canal. 

Treatment of the Acute Stage. — The proper regulation of the diet, 
exercise, and mode of life of the patient, is of the first importance 
in every stage of gonorrhoea. In the treatment of the inflamma- 
tory stage, as well as in the abortive treatment of the first stage, if 
the patient can keep his bed for a few days, the battle is half won. 
The advantages of absolute repose and quiet should be placed 



TREATMENT OF THE ACUTE STAGE. 61 

prominently before him, and every inducement be offered to lead 
him to avail himself of them. Yet in practice, we find that very 
few will submit to this constraint. It is very well to say that 
every patient that puts himself under the care of a physician, 
should follow his advice implicitly in all things ; but we must take 
the world as we find it, and the calls of business, or the necessity 
of secrecy, often render the insistence upon such stringent rules 
impossible. "When life is in danger, men absorbed in business 
will stay at home, but not merely for an attack of gonorrhoea. 
This indeed should not prevent our doing our best to persuade 
them, but we shall succeed in but a small minority of cases. 

Exercise of all kinds should be avoided as much as possible ; 
walking, dancing, riding on horseback, and standing — in the street, 
at the desk, at a party — are all injurious. Eiding is certainly less 
objectionable than walking, and yet a long ride, even in a rail-car, 
often aggravates a gonorrhoea or induces a relapse when it is appa- 
rently cured. At home, and at the store or office, the recumbent 
posture should be maintained as much as possible. It is highly 
important, also, that the genital organs should be well supported 
by a suspensory bandage. The kind of bandage is immaterial, 
provided it fit well and do not chafe the parts ; and of these condi- 
tions the surgeon should satisfy himself by actual observation. 
"While the more acute symptoms continue, the diet should be 
exclusively farinaceous; and meat, stimulants, asparagus, coffee, 
and acids be forbidden. The perusal of all books calculated to 
excite the passions, and the company of lewd women, even if no 
improprieties be committed, should be strictly interdicted. The 
last-mentioned caution is not generally given without good reason. 

At the commencement of the treatment of a case of gonorrhoea 
in the acute stage, it is well to administer an active purge, as five 
grains of calomel combined with ten of jalap, a full dose of Epsom 
salts, or three or four compound cathartic pills of the U. S. P. If 
the inflammatory symptoms be severe, marked benefit will be de- 
rived from the application to the perineum of half a dozen leeches, 
which, however, are rarely absolutely necessary. Care should be 
taken to keep the head of the penis free from any collection of 
matter, lest balanitis be excited or the disease aggravated by its 
presence. A pair of triangular-shaped drawers, like ordinary swim- 
ming drawers, worn next the skin, affords the best protection to the 
patient's linen. Water, as hot as can be borne, is the most grateful 



62 URETHRAL GONORRHCEA IN THE MALE. 

local application that can be used. I have found that it generally 
affords great relief to the scalding in micturition and the local pain 
and uneasiness, and can fully indorse Mr. Milton's statement with 
regard to it. " The only direct application which I can safely say 
has never disappointed me, which is at once safe, simple, and 
useful, is that of very hot water to the penis. But to obtain the 
really good effects it offers, the water must be hot, not lukewarm. 
In fact, we seldom see so much good ensue as when it is carried to 
the extent of producing some excoriation and faintness; thus 
applied, and especially in the early stages of the disease, the 
weight felt about the testicles soon disappears, the pain on making 
water and using injections is soothed, and the prepuce and glans 
rapidly regain a more normal temperature and color." 1 

After the operation of the cathartic, we may, in most cases, 
commence at once with copaiba or cubebs, rules for the exhibition 
of which will presently be given at length. If, however, the penis 
be still much swollen, and the scalding on passing water severe, we 
may defer the exhibition of the anti-blennorrhagics for a few days, 
and administer alkalies or diuretics, either alone or combined with 
sedatives, for the purpose of rendering the urine less irritating by 
diminishing its acidity, or diluting its contained salts by increasing 
its quantity. Again, both these classes of remedies may be given 
at the same time. From one to two drachms of the chlorate, 
acetate, or nitrate of potash, or two or three drachms of liquor 
potassse, may be added to a pint of flaxseed tea ; and the patient 
be directed to take this quantity in the course of twenty-four 
hours. The following is also an excellent formula : — 

R;. Potassse bicarbonatis 5ij« 

Tincturse hyoscyami 3J. 

Mucilaginis j§v. 
M. 
A tablespoonful every three hours. 

Do not mix tincture of hyoscyamus and liquor potassse in the 
same prescription, since the effect of the former is destroyed by 
the presence of a caustic alkali. 2 In this stage of the disease, Mr. 
Milton highly recommends the following : — 

1 Milton on Gonorrhoea, p. 21. 

2 See Paris's Pharmacologia, Ninth Edition, p. 512. This fact has recently been 
brought forward as new, and confirmed by actual experiment, by Dr. Garkod ; 
Medico-Chirurgical Transactions, Second Series, vol. xxiii. London, 1858. 



TKEATMENT OF THE ACUTE STAGE. 63 

ty. Pulv. potassae chloratis gij. 
Aquae bullientis §v. 

Misce et adde — 
Liquoris potassae ^iij. 
Potassae acetatis 5"j ad 5 v. 
Misce et cola. 
One ounce three times a day. 

If the bowels be not freely open, Mr. Milton adds powdered rhu- 
barb to each dose of this mixture, in sufficient quantity (gr. v ad 
9j) to produce two or three loose stools daily. The following is 
another formula recommended by Mr. Milton : — 

fy. Potassae acetatis ^j. 

Spiriti aetlieris nitrici 5iij« 
Aquae camphorae 3VJ. 
M. 
One ounce three times a day. 

An elegant and convenient method of administering an alkali is 
by means of Brockedon's wafers of bicarbonate of potassa, of which 
two may be given after each meal. The only objection to them is 
their expensiveness. 

If the penis be much, swollen and florid, the meatus contracted 
by the distension of its walls, and the urethra in a state of great 
sensibility, the above general measures should constitute the only 
treatment, and no local remedies, with the exception of hot water, be 
resorted to, until the inflammation has somewhat subsided. In the 
majority of cases, however, especially when the patient has had go- 
norrhoea before, the local symptoms are not severe, even in the acute 
stage, and the point of a syringe can be gently introduced within 
the canal without exciting much pain. When this is the case, an 
injection containing glycerin and strongly opiated, will be found to 
afford great relief to the local pain and uneasiness, and hasten the 
subsidence of the inflammatory symptoms, and the diminution of 
the discharge. I can speak very decidedly in favor of this appli- 
cation and of its perfect safety; but the opium must not be added 
in the form of tincture, or the alcohol, which is an irritant, will 
counteract its effect; and the fluid is to be injected with gentleness, 
and not with such force as to painfully distend the canal. The 
following is the formula that I use : — 

R. Extracti opii ^j. 

Glycerin §j. 

Aquae 3 iij . 
M. 
Injection to be used after every passage of urine. 



64 URETHRAL GONORRHOEA IN THE MALE. 

In many cases of a subacute form, half a grain or a grain of sul- 
phate or acetate of zinc may be added to each ounce of the mixture, 
even at the outset, and there are but few cases in which it is not 
admissible in the course of twenty -four or forty-eight hours, when 
the inflammation, local pain, and scalding are generally found to 
be much improved. If the case continue to progress favorably, 
the quantity of the astringent may be gradually increased, and that 
of the opiate diminished ; and the treatment should be continued 
according to the rules laid down for the third stage, to be mentioned 
presently. 

While pursuing the treatment of the acute stage of gonorrhoea, 
care should be taken that antiphlogistic measures be not too long- 
persevered with. It should be remembered that the natural tend- 
ency of the disease is to lower the tone of the system, and a con- 
dition of debility in turn reacts on the disease and prolongs its 
duration. We often meet with patients who have treated them- 
selves with low diet and daily purging for weeks, and yet who are 
no better of their gonorrhoea. An antiphlogistic course alone may 
relieve the more acute symptoms, but it will not cure the complaint ; 
and so soon as the pain in passing water has diminished and the 
local inflammation in a measure subsided, the patient should no 
longer be confined to his room, and should have a more liberal 
diet; nor, under any circumstances, should his confinement and 
abstinence be prolonged, if, after a reasonable time, they are found 
to produce no change for the better, or the pulse becomes feeble, 
the skin clammy, and the strength exhausted. Indeed, in some 
cases, in which the constitution is enfeebled by disease, debauch, 
or previous attacks of Venereal, it is necessary to abstain from all 
measures calculated to lower the tone of the system, and resort to 
good living and even quinine, iron, and other tonics, from the very 
outset of the disease. It is, therefore, to be expressly understood 
that the antiphlogistic treatment here recommended, is intended to 
apply, in its full force, chiefly to the disease as it appears in first 
attacks in men of full habit. Those patients who have had nume- 
rous previous attacks will rarely require such active treatment in 
any stage of the disease. The judgment of the surgeon must 
determine the indications of each individual case. 

Treatment of the Stage of Decline. — A marked diminution of the 
scalding in making water, and of the painful sensations in the penis, 
is, I believe, a better index of the subsidence of the inflammatory 



TREATMENT OF THE STAGE OF DECLINE. 65 

action, than the character of the discharge, which, independently 
of treatment, often continues copious and purulent after the third 
stage has fairly commenced. 

In giving directions as to the regimen of a patient in the third 
stage of gonorrhoea, some regard should be paid to his usual mode 
of life. As a general rule, all indulgence in spirituous or malt 
liquors should be strictly forbidden, and total abstinence be prac- 
tised until the cure is complete, and for at least a fortnight afterward. 
You will meet with some patients, however, who have been free 
drinkers for years, and who will not well bear the total loss of their 
stimulus, without becoming so debilitated that their gonorrhoea is 
thereby prolonged and more difficult to cure. In these exceptional 
cases, it is better to allow a glass of claret, sherry, or even brandy 
and water, to be taken with the dinner. In any case, malt liquors 
should be avoided, since they are decidedly more injurious than 
other liquors which contain a larger amount of alcohol. The 
patient may now return to a more generous but simple diet, though 
salt meats, highly seasoned food, asparagus and cheese should still 
be avoided. The bowels are not to be allowed to become consti- 
pated, and this should be prevented so far as possible by regulating 
the diet. One or two free stools a day are desirable. If the patient 
have been confined to the house during the acute stage, he may 
now be allowed to go out, but should be cautioned against walking 
or standing more than is necessary, and the genital organs should 
be well supported by a suspensory bandage. Patients often inquire 
whether the use of tobacco is injurious; I believe that it is, and 
that either smoking or chewing, especially in excess, relaxes the 
genital organs and tends to keep up a urethral discharge. I have 
frequently been told by patients subject to spermatorrhoea, that 
smoking during the evening would invariably be followed by an 
emission during the night, and I am satisfied that many cases of 
gonorrhoea are prolonged by the excessive use of tobacco. I there- 
fore recommend entire abstinence, or, at least, great moderation, 
both in smoking and chewing, to persons suffering with this dis- 
ease. 1 

The chief remedies adapted to the third stage of gonorrhoea are 

1 Dr. Shipley has recently published two cases of gonorrhoea in which the dis- 
charge repeatedly disappeared on leaving off smoking, and returned on resuming it. 
(Boston Med. and Surg. Journal, Nov. 22, 1860.) 
5 



66 URETHRAL GONORRHOEA IN THE MALE. 

injections, and copaiba and cubebs. By far the more important of 
these are injections, which, constitute our chief reliance in the 
treatment of this affection, when it has arrived at this stage ; and, 
in spite of all that has been written and said against them, I do not 
hesitate to say, that the surgeon who voluntarily renounces injec- 
tions, deprives himself of his best weapon in contending with 
gonorrhoea, and is comparatively impotent in his attempts to con- 
quer it. 

The objections that have been raised against this mode of treat- 
ment need not long detain us. They are chiefly the following : 
1. It is asserted that the injected fluid carries before it the muco- 
pus within the urethra, and thus extends the disease to the deeper 
portions of the canal. Supposing this possible in any case, it cannot 
take place, if the patient pass his water before injecting, as he should 
always be directed to do. 2. It is said that injections may excite 
swelled testicle and other complications of gonorrhoea. This is 
only possible, when they are used of too great strength or with 
undue violence. 3. The chief objection that has been alleged 
against injections is, that they are a frequent cause of stricture of 
the urethra. This the opponents of injections have endeavored to 
prove, by showing that most persons, with stricture preceded by 
gonorrhoea, were treated for the latter disease by injections. This 
is clearly a mode of reasoning, post hoc ergo propter hoc, and by no 
means proves the ground assumed. I have heard of some one, who, 
to show its fallacy, instituted some inquiries among patients with 
stricture, as to whether they had taken flaxseed tea for their pre- 
vious gonorrhoea, and was able to prove, if such reasoning be relia- 
ble, that flaxseed tea is a very fruitful source of stricture. As 
Eicord justly states, it is much more probable that strictures are 
due to the chronic inflammation, which, in cases of gonorrhoeal 
origin, has usually preceded them for a long period, than to any 
influence exercised by injections. The well known effect of chronic 
inflammation of a mucous membrane in producing an effusion of 
plastic material in the sub-mucous cellular tissue which by its con- 
traction diminishes the calibre of the canal, is a strong argument 
in favor of this view. The objections to the use of injections are, 
I believe, founded on their abuse, or on false reasoning, and will 
not stand the test of examination. When properly used, they con- 
stitute the most valuable means within our reach for the cure of 
gonorrhoea, and are employed in the practice of all surgeons, with 



TREATMENT OF THE STAGE OF DECLINE. 67 

very few exceptions, who have had the opportunity of testing their 
value. 

Injections are particularly adapted to the treatment of the first 
stage by the abortive method and to the treatment of the third 
stage of gonorrhoea ; although, as already stated, in very many cases 
they may be used with safety and benefit in a weak form, even in 
the second or acute stage. 

These remarks in favor of injections do not of course imply that 
they are infallibly successful, nor that they can be used indiscrimi- 
nately in all cases. Under certain circumstances, their effect is 
found to be injurious. If in the course of treatment the patient 
complain of a frequent desire to pass his urine, and other symptoms 
indicating inflammation of the neck of the bladder or prostate, in- 
jections should be at once suspended. Continuous pain in the 
penis, or any considerable amount of tumefaction of its tissues also 
contra-indicates the use of irritant or astringent injections, although 
the formula containing glycerin and extract of opium, which was 
recommended in the acute stage, may still, in many cases, be em- 
ployed with advantage. Moreover, it should not be forgotten that 
injections will sometimes keep up a discharge through the irrita- 
tion which they excite, however simple may be their composition. 
After the force of the disease has been subdued, they should there- 
fore be used at gradually increasing intervals, or, from time to 
time, be altogether omitted, until the necessity of their continuance 
again becomes apparent. 

The manner of using the syringe in the third stage is essentially 
the same as in the abortive treatment of the first stage. A larger 
syringe, however, should be employed, one, for instance, holding 
three or four drachms ; since there is now no necessity of limiting 
the action of the injection posteriorly, and, on the contrary, it is 
desirable to extend it as far back as possible, in order that it may 
reach the whole diseased surface. For this purpose the finger may 
be run along the under surface of the urethra from before back- 
wards, as well as in the opposite direction (from behind forwards), 
as previously recommended, in order to insure complete distension 
of the canal and exposure of its lacunae. The patient should always 
pass his water before injecting, and throw in two syringefuls at 
each application. 

A great variety of substances have been recommended as the 
active principles of injections. A choice, to a certain extent, is 



68 URETHRAL GONORRHOEA IN THE MALE. 

doubtless desirable, since the same injection does not always suc- 
ceed equally well in all cases. For instance, one of my patients, 
whom I have repeatedly treated for gonorrhoea, is always made 
worse by an injection of sulphate of zinc, and is benefited by a 
weak solution of nitrate of silver. Peculiarities of this kind are 
occasionally met with, but I believe that much time is wasted by 
young practitioners in changing from one to another of the many 
varieties of injections proposed in books, under the supposition that 
some specific effect is to be obtained from the contained ingredients, 
whereas, in most cases, success depends upon the thoroughness of 
the application, and attention to the general health and any existing 
complications. 

My own preferences for an astringent as the active principle of 
injections in the third stage of gonorrhoea, are very strongly in 
favor of the sulphate of zinc ; which is also the favorite injection of 
Sigmund of Vienna, Mr. Milton, and many other eminent surgeons. 
I have already spoken of the addition of a small quantity of this 
salt to the sedative injections of the acute stage, after the more in- 
flammatory symptoms have been subdued. The proportion of the 
sulphate may be increased and that of the opiate diminished, as the 
case progresses, and the latter finally omitted altogether. The 
strength of the injection should be such that it may excite a slight 
uneasy sensation in the urethra for about ten minutes, but it must 
not be strong enough to cause severe or long- continued pain. As 
the case approaches a cure, the injection will cease to excite any un- 
pleasant feeling whatever, and its strength need not be further 
increased. In most cases, we need not at any period exceed the 
proportion of the sulphate in the following formula : — 

I£. Zinci sulphatis gr. xij. 

Aquae 3iv. 
M. 

Glycerin may be substituted for half an ounce or an ounce of the 
water. As to the frequency with which the injection is to be used, 
I usually direct the patient to inject after each passage of his urine, 
with the expectation that he will take four or five injections in the 
course of the twenty-four hours. It is better that the last injec- 
tion should be applied an hour or two before retiring, since if used 
directly before going to bed, it favors the occurrence of erections 
and chordee during the night. 

If the discharge do not materially diminish under the use of these 



TBEATMENT OF THE STAGE OF DECLIKE. 69 

injections, combined, in most cases, with the internal administration 
of copaiba or cubebs, I usually resort to a solution of nitrate of silver, 
of the strength of from two to five grains to the ounce of water, and 
inject it myself for the patient, daily, or every two or three days, 
while at the same time he is directed to continue his injection of 
sulphate of zinc. The effect of an irritant like nitrate of silver 
should be closely watched, and its administration should not, there- 
fore, be left to the patient himself. 

The acetate of zinc is nearly, if not quite as valuable a remedy 
as the sulphate, and the remarks above made in favor of the latter 
are equally applicable to the former. Indeed, if I were asked to 
name the simplest treatment of gonorrhoea, and the one best adapted 
to the largest number of cases, I should reply: a weak injection of 
the sulphate or acetate of zinc, containing from one to three grains 
to the ounce of water. Many men about town constantly carry in 
their pockets a prescription of this kind (generally with the addition 
of a little morphine or a few grains of powdered opium), with which 
they almost invariably succeed in arresting their frequent attacks of 
gonorrhoea, without resorting to the nauseous anti-blennorrhagics, 
or finding it necessary to consult a surgeon. A great reputation 
has been acquired for a reddish powder sold by an irregular prac- 
titioner of this city, who tells his patients that the ingredients are 
entirely unknown to the profession. This powder, subjected to 
chemical analysis, is found to contain as coloring matter Armenian 
bole, and as an active ingredient acetate of zinc. 

The sulphate of zinc was a favorite with Dr. Graves, who was in 
the habit of combining it with the impure carbonate of zinc, as in 
the following formula : — 

I£. Zinci sulphatis gr. iij. 

Calamiuae gr. x. 

Mucilaginis 5ij» 

Aqua? 5vj. 
M. 

"With regard to the addition of calamine, Dr. Graves says : " How 
the lapis calaminaris acts, unless on a mechanical principle, it is 
difficult to explain ; but of its utility I am certain, having long used 
this combination, as recommended in Thomas's Practice of Physic." 1 

The chloride of zinc is a powerful caustic and irritant which 
fulfils, although in a much less perfect manner, the same indications 

1 Clinical Lectures, London Med. Gaz., new series, vol. i., 1838-9, p. 438. 



70 UEETHEAL GONOEEHCEA IN THE MALE. 

as nitrate of silver, and may, therefore, be used under similar 
circumstances. It is a favorite injection with, some practitioners, 
and especially with my venerable friend, Dr. J. P. Batchelder, who 
employs a very strong solution in all stages of gonorrhoea, and 
states that but few cases resist more than a week. Dr. B. dissolves 
5ij of the chloride in 3iij of water, and directs the patient to com- 
mence with three drops of the mixture to a tablespoonful of water, 
and inject three times a day; to add a drop at a time (rarely 
exceeding eight drops) until a smarting sensation is produced ; and 
then gradually to diminish the strength until the discharge disap- 
pears. In several trials which I have made of this method I have 
been disappointed in the results; and, in general, I regard the 
action of the chloride of zinc as much inferior to the nitrate of 
silver, and not without danger, and would limit its use to certain 
cases of gleet in which it is desired to set up acute inflammation. 

Of the numerous other formulae for injections sometimes employed 
in the treatment of gonorrhoea, the following are among the best : — 

E:. Cupri sulphatis gr. xij. 

Aquse ^iv-vj. 
M. 

fy. Liq. plumbi subacetatis §ss-j. 

Aquse q. s. ad §iv. 
M. 

]£. Aluminis gr. xij-xxx. 

Aquse ^iv. 
M. 

Mr. Milton says of alum : " The absence of pain which follows 
its use, and its feeble curative power, have led me to assign to it 
only a secondary rank. I am, indeed, extremely doubtful if it 
possess any superiority over very mild injections of nitrate of silver 
or sulphate of zinc, and would, therefore, confine its exhibition to 
those cases accompanied by severe pain, where it may, during a 
day or two, serve as a pioneer to the others." 

In the following we have a combination of alum and sulphate of 
zinc : — 

E^. Liq. aluminis comp. §j. 

Aquse §iij. 
M. 

The two following are excellent formulae much employed by 
Eicord : — 



TREATMENT OF THE STAGE OF DECLINE. 71 

R. Zinci sulphatis, 

Plumbi acetatis, aa gr. xxx. 

Aquae rosae ^vj. 
M. 

ty. Zinci sulphatis gr. xr. 

Plumbi acetatis gr. xxx. 

Tincturse catechu, 

Villi opii, aa. 5j» 

Aqua? rosse 5VJ. 
M. 

"Vegetable astringents may also be employed either alone or in 
combination with the salts of the metals. 



Vini rubri §vj. 

Acidi tannici gr. xviij. 



M. 



R,. Zinci sulphatis, 

Acidi tannici, aa. gr. xij. 
Aquse §iv. 
M. 
Tannate of zinc is formed by decomposition of the sulphate. 

Injections of tincture of aloes are recommended by Gramberini 1 
of Bologne, who states that they excite only a momentary smarting 
sensation, and are very efficacious. 

R,. Tinct. aloes ^ss. 

Aquse §iv. 
M. 

The subnitrate of bismuth has recently come into favor. It acts 
as a local sedative, or, when deposited upon the walls of the ure- 
thra, may possibly serve to protect the diseased surfaces from con- 
tact. Of 52 patients treated exclusively with injections of subnitrate 
of bismuth, 36 recovered after an average treatment of twenty -two 
days. 2 I have found only one difficulty attending its use, viz., that 
it clogged up the urethra, and by its mechanical presence excited 
an uneasy sensation, which was only relieved by the passage of the 
urine. As it is not soluble in water, it should be suspended by 
means of mucilage, and the bottle be shaken before using. 

R> Bismuthi subnitratis 31J. 

Mucilaginis §ss. 

Aquae giijss. 
M. 



1 Rev. de Ther. Med.-Chir., Jan. 1, 1860, p. 13. 

2 Victor de Mebio; Report to the Medical Society of London, April 30, 1860. 



72 URETHRAL GONORRHCEA IN" THE MALE. 

Finally, in many cases of gonorrhoea, simple iced- water injected 
after each passage of the urine, is very serviceable in allaying pain 
and irritation, and not inefficacious for the cure of the discharge. 

Copaiba and Cubebs. — Certain drugs which appear to possess a 
peculiar power in arresting inflammation of the urethral mucous 
membrane, are called anti-blennorrhagics. The chief of them are 
copaiba and cubebs. Some interesting investigations made by 
Eicord to determine the mode of action of these agents, are given 
in Eicord and Hunter on Venereal. It had already been observed 
in practice that copaiba and cubebs had but little curative effect 
upon gonorrhoea of any portion of the male or female genital 
organs, except the urethra ; and it was hence suspected that they 
acted chiefly by their presence in the urine, and not through the 
general circulation; but this fact had not been demonstrated. A 
man with gonorrhoea chanced to enter Eicord's ward at the Hopital 
du Midi, who had a fistulous opening communicating with the ure- 
thra a short distance in front of the scrotum, produced by a liga- 
ture which had been applied around his penis when a child. He 
could at will, by separating or approximating the two edges of the 
fistula, either make his urine emerge from the artificial orifice, or 
cause it to traverse the whole extent of the urethra. Both portions 
of the canal were affected with gonorrhoea. 

Eicord administered copaiba to this patient, and directed him to 
pass his water entirely through the fistula. In the course of a few 
days, the disease was cured in the posterior portion of the canal, 
behind the artificial opening through which the urine had passed, 
while it remained unchanged in the anterior portion. He was now 
directed to make his water pass through the whole length of the 
canal, and in a few days more the anterior portion was also cured. 
By a singular coincidence, two other cases, of a similar character, 
soon after presented themselves in Eicord's wards, in one of which 
copaiba, and in the other cubebs, was given in the same manner, 
and the result in each was the same as in the case just described. 
From these experiments, Eicord concludes that copaiba and cubebs 
have but little influence upon gonorrhoea, unless directly applied to 
the diseased surface, and hence that we cannot expect decided 
benefit from their administration in any form of gonorrhoea, except 
that of the urethra in the two sexes. In gonorrhoea of the vagina 
or vulva, or in balanitis, they are comparatively useless. 

The presence of these drugs in the urine is still further evinced 



COPAIBA AND CUBEBS. 73 

by the odor which they impart to this fluid, and which is often suf- 
ficient to pervade the bedchamber occupied by the patient. 

It must not, however, be inferred that copaiba and cubebs have 
no effect except by way of the kidneys. They are often used with 
benefit in other diseases than those of the urinary organs, and 
cannot therefore be entirely destitute of action through the gene- 
ral circulation. Moreover, they sometimes act as revulsives by 
producing copious evacuations from the bowels, and the urethral 
discharge is diminished as after the administration of a purge ; their 
chief action, however, is in the manner described, by their presence 
in the urine. 

Such being the cage, it might naturally be supposed that an 
emulsion of copaiba injected into the urethra would have the same 
effect, and that thus the internal administration of so nauseous a 
drug might be avoided. The experiment has been tried in nume- 
rous instances, but the result has always been unsatisfactory. As 
stated by Eicord, both copaiba and cubebs, in passing through the 
digestive organs or kidneys, undergo some modification of an un- 
known character, upon which their curative power depends, and 
which cannot be imitated by art. 

Dr. Hardy, of Paris, is said to have effected a cure in several 
cases of vaginal gonorrhoea by giving the patients copaiba, and 
directing them to inject their urine into the vagina after each act 
of micturition. This course, however, is more interesting as an 
experiment than worthy of imitation in practice. 

It was formerly supposed that copaiba could be used with safety 
only in gleet, and even then in very small doses, and that it was 
inadmissible in gonorrhoea, especially in its acute stage, having a 
tendency, as was thought, to excite inflammation of the neck of the 
bladder and swelled testicle. In the latter part of the last century, 
however, it was discovered that the natives of South America were 
in the habit of administering copaiba in large doses in all stages of 
gonorrhoea, and this, too, with very great success. This led to a 
bolder method of administering it, and it was soon ascertained that 
its curative effect is much greater in the acute than in the chronic 
form of urethritis, and that it is rarely, if ever, productive of those 
complications which were once attributed to it. 1 In short, it would 

1 For an interesting history of the remarkable change in medical opinion with 
regard to the administration of copaiba, see Tkousseau, Traite de Therapeutique, 
vol. ii. p. 592. 



74 URETHRAL GONORRHCEA IN THE MALE. 

appear that copaiba can be administered with safety and to much 
greater advantage in the acute stage of gonorrhoea or at an early 
period of the stage of decline than afterward, and the same is true 
of cubebs. Still, when a case of this disease presents itself with 
marked inflammatory symptoms, it is usual to wait for a day or two 
until these have been somewhat subdued, by the means already 
mentioned, before commencing with copaiba or cubebs, and I do 
not think that any time is thus lost ; and, in all cases, the effect of 
the remedy is promoted by the previous exhibition of a cathartic. 
The diuretics and alkalies, spoken of in connection with the acute 
stage, may be combined with these drugs, as in some of the formulae 
to be mentioned presently, or may be given separately. 

The dose of copaiba is from twenty minims to one or even two 
drachms, repeated three times a day. It may be given in its pure 
state upon coffee, wine, or milk, but it is so disagreeable to the pa- 
late, and so likely to excite nausea, eructations, and even vomiting, 
that few persons can tolerate it in this form. To render it more 
acceptable to the taste and stomach, it is generally given in combi- 
nation ; and other ingredients are often added for the purpose of 
assisting its action upon the urethra. A very common and excel- 
lent formula is the following, which is known as the Lafayette 
mixture : — 

I£. Copaibae, 

Spirit! aetheris nitrici, aa §j. 

Liquoris potassae 5U« 

Spiriti lavandulae comp. ^ij. 

Syrup i acaciae ^vj. 
M. 
Dose. — From a teaspoonful to a tablespoonful after each meal. 

The following are also useful formulae : — 

]^. Olei copaibae, 

" cubebae, aa ^j. 
Aluminis 51J. 
Sacchari albi $iv. 
Mucilaginis 5"j« 
Aqme gij. 
M. 
Dose. — A teaspoonful three times a day. 

R:. Copaibae, 

Liquoris potassae, aa giij. 
Mucilaginis acaciae ^j. 
Aquae menthae viridis q. s. ad §vj. 
M. (Milton.) 

Dose. — One ounce three times a day. 



COPAIBA AND CUBEBS. 75 

I£. Copaibse 5 X « 

Tincturse cantharidis, 
Tincturse ferri chloridi, aa 5ij« 
M. 
Dose. — From half a teaspoonful to a teaspoonful. 

But in whatever way combined, many stomachs will not tolerate 
copaiba in a liquid form ; hence I commonly prescribe the solidified 
mass, formed by the addition of magnesia, and known in the U. S. 
Dispensatory as Pilulae Copaibas. It requires some little tact to pre- 
pare this mass ; or, rather, difficulty is met with, unless the proper 
kind of copaiba be used. Two kinds of the balsam are found in 
commerce, one of which, the best, is solidifiable with magnesia, 
and the other not. The solidified mass should be divided into 
pills, each of which may contain five grains ; and it is desirable to 
coat them with sugar, both for the purpose of preventing their ad- 
hering together, and to render them more acceptable to the palate. 
This is to be accomplished in the following manner : Put the pills 
into a vessel with sufficient water to moisten them ; then turn them 
out upon a pan and sprinkle over them finely powdered sugar, at 
the same time rolling them about by shaking the pan, so that they 
may be entirely and equally coated. This process may be repeated 
after they are dry, as many times as is necessary to give them a 
thick coating of sugar. The dose is from four to eight pills three 
times a day. Thus prepared, they leave no taste in the mouth, and, 
being slowly dissolved in the stomach, are much less likely to ex- 
cite nausea than the liquid article. 

"We have another anti-blennorrhagic, but little if at all inferior 
to copaiba, in the powdered berries of the Piper Cubeba. Cubebs 
possess the advantage over copaiba of being far less disagreeable 
to the taste, and less likely to excite nausea, eructations, vomiting, 
and diarrhoea ; and, on this account, are often to be preferred in 
the treatment of gonorrhoea. They cannot be relied upon, how- 
ever, unless freshly powdered, and preserved in a glass vessel; 
since the essential oil which they contain is rapidly absorbed by 
any porous material. Cubebs are conveniently taken, mixed in 
sweetened water, in the proportion of one to two drachms of the 
powder to half a glassful of the liquid ; and this dose should be 
repeated three or four times a day. 

Cubebs are often advantageously combined with iron, especially 
for persons of weak habit, thus : — 



76 UKETHEAL GONORRHOEA IN THE MALE. 

R;. Pulveris cubebse 5ij« 
Ferri carbonatis 5ss. 
M. et ft. pulv. 
To be taken three times a day. 

Cubebs and copaiba may be combined together in the same pre- 
scription. 

R,. Copaibse ^ij. 

Pulveris cubebse §j. 
Aluminis 5'iss. 
Magnesise q. s. ut fiat massa. 
To be divided into pills containing five grains each, of which from four to eight 
are to be taken three times a day. 

R:. Pulveris cubebne §iij. 

Copaiba? 5iss. 

Aluminis 5ij« 

Sacchari albi §j. 

Magnesise 5i ss « 

Olei cubebse, 

Olei gaultherise, aa 3J- 
M. 

This mixture forms a paste, of which the patient may be directed 
to take a piece the size of a walnut, after each meal. The following 
prescription is particularly adapted to delicate stomachs : — 

R. Copaibse §ij. 
Magnesise gj. 

Olei menthae piperitse gtt. xx. 
Pulveris cubebse, 
Bismuthi subnitratis, aa 3 ij . 
M. 
To be divided into pills of five grains each, and coated with sugar. 

R. Copaibse |j. 

Magnesise 5ss. 

Pulveris cubebse §iss. 

Ammonise carbonatis 3ij« 

Ferri sulphatis [)j. 
M. (Meot.) 

To be divided into pills of five grains each : dose, three, three times a day. 

Copaiba and cubebs may also be obtained enveloped in capsules 
of gelatin, and this is a popular form of administration. I am not, 
however, partial to these preparations. The capsules do indeed 
obviate the disagreeable taste of these drugs, but they do not pre- 
vent nausea and eructations, when their contents are suddenly dis- 
charged into the stomach, by the solution of the envelope. I very 
much prefer the French dragees which have been introduced within 



COPAIBA AND CUBEBS. 77 

the last few years, and of which there are several varieties ; some 
containing copaiba alone, others cubebs, and others still both these 
drugs combined with iron ; I have found them all to be very reli- 
able. The dose is from four to six, three times a day. In my own 
practice, I usually prescribe these dragees, or one of the above for- 
mulae for pills of the solidified copaiba with cubebs, or simple 
cubebs in powder. I am also in the habit of prescribing some 
form of iron, either alone or in combination with the anti-blennor- 
rhagics, in the majority of cases, after the more acute symptoms 
have passed. 

Injections of an emulsion of copaiba into the rectum, in cases 
where it is not borne by the stomach, have been recommended, 
especially by Yelpeau. I have never tried this method of adminis- 
tering copaiba, and should have but little faith in its efficacy. It 
is acknowledged that a much larger quantity must be used than 
when it is given by the mouth. A simple injection should first be 
employed to clear the rectum of fecal matter, when the following 
mixture may be thrown in : — 

I£. Copaibse 5 v. 

Ovi vitelli No. j. 

Extracti opii gr. j. 

Aquse §viss. 
M. 

The nausea, eructations, and diarrhoea, which are often excited 
by copaiba, have already been referred to, and sometimes render it 
impossible to administer this remedy in any form to a delicate sto- 
mach. The diarrhoea may often be controlled by the combination 
of alum or an opiate, but more frequently requires the drug to be 
suspended, and afterward resumed in smaller doses. 

Copaiba sometimes, also, gives rise to a cutaneous eruption, be- 
longing to the class of exanthemata, as roseola, erythema, or urti- 
caria. Such eruptions should be carefully distinguished from those 
of secondary syphilis, as may readily be clone by the absence of 
coexisting syphilitic symptoms, by the itching that usually attends 
them, and by their disappearance in a few days after the copaiba 
is suspended. The administration of copaiba should never be con- 
tinued, if it produce this effect. 

Another unpleasant symptom not ^infrequently occasioned by 
copaiba, is pain in the region of the kidneys, dependent upon con- 
gestion of those organs. A few years ago, a patient was under my 



78 UKETHKAL GONORRHCEA IN THE MALE. 

care for gonorrhoea; who had previously had several attacks of 
hematuria. Contrary to my advice, he took copaiba, which in- 
duced a return of the blood in his urine, and I afterward learned 
that the administration of this drug had already produced a similar 
effect in a former attack of gonorrhoea. I always consider the 
presence of pain in the kidneys an indication that the copaiba 
should be omitted ; for we have no right, in these days when renal 
disease is so common, and a healthy kidney so rarely met with at 
a post-mortem examination, to subject our patients to the risk of 
permanent injury. 

Cubebs may occasion, though much more rarely, any of the 
unpleasant symptoms just mentioned as likely to occur from co- 
paiba. Both of these drugs, in large doses, will, in rare instances, 
excite severe headache, giddiness, and even more serious symptoms 
connected with the nervous centres. Eicord mentions a case of 
temporary hemiplegia, and another of violent convulsions, produced 
by copaiba ; in both instances, these serious symptoms were followed 
by the outbreak of a cutaneous eruption, also dependent on the 
drug. 

The anti-blennorrhagics now mentioned, are of undoubted efficacy 
in the treatment of many cases of gonorrhoea, but in others they 
utterly fail ; nor have we any means of distinguishing these two 
classes of cases beforehand. As I have already stated, I think they 
hold a second rank to injections in the cure of this disease. As a 
general rule, if they are likely to prove successful, their good 
effect will be apparent in a fortnight or three weeks from their 
commencement, and if, by this time, the disease continue unabated, 
they should be omitted and other means employed to effect a cure. 
When long continued, they produce disorder of the digestive func- 
tions, impair the appetite, and induce general malaise and debility ; 
a condition of the system highly calculated to prolong the duration 
of gonorrhoea. Though often of marked benefit, they are by no 
means indispensable in the treatment of every case of gonorrhoea. 

Obstacles to Success. — A mistake, generally committed by patients 
who treat themselves for gonorrhoea and by some physicians, espe- 
cially in the early years of their practice, is over-medication and 
a neglect of the general health. Nothing is more common than to 
meet with a patient, suffering from gonorrhoea of several months' 
standing, who has been kept on low diet, and been taking various 
preparations of copaiba and cubebs, using a variety of injections 



OBSTACLES TO SUCCESS. 79 

often exceedingly irritant in their composition or strength ; and 
who is now run down, weak in body and despairing in mind. His 
digestion is impaired, his appetite gone, and his clap as bad as ever. 
Let such a man lay aside his capsules, pills, powders, mixtures and 
irritant injections ; give him substantial food, and a tonic, as quinine 
or iron ; limit the special treatment of his disease to a weak astrin- 
gent injection, as from one to three grains of sulphate of zinc to 
the ounce of water, and his disease will probably begin to improve 
at once, and subside entirely in the course of a few days or weeks. 
Under any circumstances, you will have removed one great obstacle 
to a cure, and if the discharge do not entirely disappear, it is pro- 
bably kept up by some local complication, which can now be 
attacked with a prospect of success. The following is a type of 
this class of cases. 

Case. P. A., aged 19, applied to me on May 5th, 1857, for a gonor- 
rhoea which he contracted about the middle of January. He had been 
under the care of several physicians, and had treated himself a portion 
of the time ; had taken copaiba in almost every form, and cubebs in large 
quantities ; and had used strong injections of nitrate of silver, sulphate 
of zinc, alum and acetate of lead. He was now much debilitated, and 
complained of general malaise and loss of appetite, and the discharge 
was still copious. I passed a bougie to ascertain if he had stricture, but 
could discover none. I then directed him to abstain from all anti-blen- 
norrhagics and to live well, and prescribed five grains of citrate of quinine 
and iron to be taken with each meal, and an injection of sulphate of zinc, 
three grains to the ounce. 

In one week from the time I first saw him, the discharge had disap- 
peared. There was a slight return of it a few days afterward which lasted 
only for a day or two, and did not again appear. 

In the large class of cases of which this is a type, the disease is 
kept up by a debilitated condition of the system, and requires for 
its removal general hygienic measures, and in most cases tonics. 
I have found the citrate of iron and quinine, and the tincture of 
the chloride of iron, most serviceable. 

Independently of debility, the chief causes of the continuance of 
a gonorrhoeal discharge are the existence of stricture and irritation 
of the neck of the bladder. It is desirable in every obstinate case 
to ascertain if the former be present by the passage of a full-sized 
bougie, and if any obstruction be met with, appropriate treatment 
should at once be adopted. 



80 UKETHRAL GONORRHCEA IN THE MALE. 

It sometimes happens that a case of gonorrhoea has been going 
on well for a week or ten days under the use of the anti-blennor- 
rhagics and injections — the discharge has almost entirely ceased 
and the patient considers himself nearly well, when suddenly a 
relapse takes place ; the discharge is once more thick and purulent ; 
the scalding in making water returns; the injection, which has 
scarcely been felt for a number of days, excites considerable pain, 
and at the same time the patient has a frequent desire to pass his 
urine, and suffers from an uneasy sensation in the perineal region. 
The latter symptoms denote that the disease has extended to the 
deeper portion of the urethra, and that there is irritation or inflam- 
mation of the neck of the bladder. Under these circumstances, 
the case requires to be very carefully watched and judiciously 
treated. Unless great care be used, the inflammation may extend 
through the vas deferens to the scrotal organs, and swelled testicle 
ensue; or the prostate gland may become involved. If irritant 
injections now be used, they will prove inefficient and will aggra- 
vate the symptoms. It is best to suspend the use of injections 
altogether, and to resort to the exhibition of alkalies and sedatives, 
as recommended in the inflammatory stage, until the subsidence of 
the symptoms shall enable us to resume direct treatment ; the patient 
should also be particularly careful with regard to exercise. Canada 
turpentine, the product of the Abies Bahamea, will also be found of 
essential service in these cases, in place of the anti-blennorrhagics, 
which should be omitted. It may be made into pills containing 
five grains each, of which from six to twelve should be taken 
daily. Still another remedy of value is blistering the penis or 
perineum, in the manner which I shall describe in connection with 
gleet. 

Treatment of Special Symptoms. — It remains to speak of the treat- 
ment of certain special symptoms which may attend a case of 
gonorrhoea, and one of the most annoying of these is chordee. 
Yarious sedatives are employed for the relief of this symptom, 
among which camphor holds the first rank. This may be given 
in the form of a pill, combined with extract of lettuce or opium, as 
in the following formulae : — 

I£. Lactucarii, 

Pulveris camphorse, aa 9ij. 
M. ft. pil. No. xx. 
Dose. — Two at bedtime. (Ricord.) 



TREATMENT OF SPECIAL SYMPTOMS. 81 

R. Pulveris camphorse ^iss. 

Pulveris opii gr. x. 
M. ft. pil. No. x. 
Dose. — One or two. (Ricord.) 

Mr. Milton prefers camphor in a liquid form in large doses. He 
directs the patient to take one drachm of the tincture in water on 
going to bed, and every time he wakes up with chordee, to repeat 
the dose. He states that after the continuance of this treatment for 
two or three nights all tendency to chordee disappears. 

Lupulin is another remedy of undoubted power in allaying the 
excitability of the genital organs, and possesses the advantage over 
opium that it does not constipate the bowels. It may be given in 
doses of fifteen grains, triturated in a mortar with sugar. This 
quantity is to be taken before going to bed, and may be repeated 
one or more times in the night if required. 

Of the above means of relieving chordee, I regard Mr. Milton's 
method of giving camphor, if it do not disagree with the stomach, 
and the administration of lupuline, as the best; yet none of the 
remedies mentioned can be relied upon with certainty of producing 
the desired effect, for they all fail in many instances. Much may 
be accomplished by directing the patient to avoid eating or drink- 
ing for some hours before going to bed, to be careful to empty his 
bladder and rectum, and to sleep on a hard mattress, with but few 
"bedclothes over him. The position in bed is also of importance, 
since erections are much less likely to take place when lying upon 
the side than upon the back. I have sometimes directed a suppo- 
sitory of hyoscyamus and belladonna to be introduced into the 
rectum with good effect. 

Another means of relief which I have found highly successful is 
bathing the genital organs in very hot water directly before going 
to bed. The reaction after the application of heat has a sedative 
effect, and in this respect has exactly an opposite influence to that 
of the cold lotions which are sometimes advised. 

Hemorrhages from the urethra, occurring during erections, if 
slight, require no treatment. When copious, they are to be arrested 
by quiet, the horizontal posture, the application of ice externally, 
and the injection of ice- water into the canal ; and severe cases may 
require compression effected by the introduction of a bougie within 
the urethra, and a bandage around the penis, or a compress to the 
perineum. 
6 



82 URETHRAL GONORRHOEA IN THE MALE. 

If abscesses form along the course of the urethra, they should 
be opened at an early period, for fear that they may break inter- 
nally, and thus give rise to urinary abscess and fistula. 

As an attack of gonorrhoea is passing off, it not unfrequently 
happens that the discharge assumes an intermittent character, 
entirely disappearing for a few days, and then, without apparent 
cause, reappearing for a day or two. This may occur several times 
in succession, and in some cases that I have witnessed, it has 
assumed great regularity. The surgeon should, of course, assure 
himself that the return of the symptoms is not due to imprudence, 
and, if satisfied of this, is generally safe in telling the patient that 
his disease will soon cease entirely to annoy him. 

It is important to continue treatment for some days after all 
traces of the disease have passed away, since relapses are very 
readily induced. They are usually brought on by the patient's 
neglecting the rules with regard to exercise, diet, etc., already laid 
down, or by his indulging in sexual intercourse. He should be 
particularly cautioned on these points, and should be directed to 
continue his medication, both external and internal, in decreasing 
doses, for at least ten days after the lips of the meatus have ceased 
to be glued together in the morning. Until every symptom of 
gonorrhoea has disappeared for this length of time, the patient 
cannot consider himself as securely well, and should still be 
cautious in his habits for a fortnight longer. 

The reader may be interested to know what is the average 
duration of treatment required in the hands of the best surgeons 
for the cure of gonorrhoea, laying aside those cases which are seen 
in the first stage, and which are speedily cured by the abortive 
method. This may be estimated at three or four weeks. Greater 
success, on the average, is probably not attainable by any means 
with which we are at present acquainted. 






GLEET. 83 



CHAPTER II. 

GLEET. 

The term " Blennorrhoea," or, in common parlance, "Gleet," is 
applied to a slight and chronic discharge from the male urethra, 
unattended by symptoms of acute inflammation. 

Gleet generally follows without interval an attack of gonorrhoea, 
as a consequence of the neglect or unsuccessful treatment of the 
latter ; and, as the acute gradually subsides into the chronic disease, 
it is impossible clearly to define a line of demarcation between 
them, and to say when the former ceases and the latter begins. In 
many cases, however, gonorrhoea runs through its successive stages 
and is apparently cured ; when, after an interval of several weeks 
or even months, the patient returns with the report that he has 
recently noticed in the morning on rising that the lips of his meatus 
adhere together, and, on separating them, that the urethra contains 
a small amount of matter ; he sutlers no pain or inconvenience, but 
is still anxious about his discharge and desires to be free from it. 
In such instances, it is probable that the cure of the preceding 
urethritis was only apparent, and that a slight degree of inflam- 
mation was left in the deeper portions of the canal, not manifesting 
itself externally until aggravated by some exciting cause, as coitus, 
alcoholic stimulants, fatigue, etc. Or, again, it is not improbable 
that there is a stricture of the urethra, which is the most frequent 
cause of the continuance of a gleety discharge following an acute 
attack of gonorrhoea. Other organic changes may exist within the 
canal and be productive of gleet, as vegetations similar to those 
met with upon the internal surface of the prepuce, and in rare 
instances, polypoid growths. 1 

Idiopathic gleet, or gleet not preceded by acute urethritis, may 
be dependent upon various affections of the prostate, and espe- 
cially upon the hypertrophy of this gland so common in old men. 

1 See Thompson on Stricture, p. 73 et seq. 



84 GLEET. 

It may also arise from disorder of the digestive function, and from 
disease of the bladder or kidneys, whereby the urine is rendered 
abnormally irritant. 

Gleet is often maintained by a state of general debility, or by a 
strumous, rheumatic, or gouty diathesis. That general debility is 
a fruitful source of the persistence of gleet, is evident from the fre- 
quency of this disease in persons of broken-down constitutions, and 
from the beneficial influence of tonics and general hygienic mea- 
sures in its treatment. Again, gleet is peculiarly frequent and 
obstinate in persons of a strumous diathesis who are subject to 
chronic inflammation of other mucous membranes, and under such 
circumstances is benefited by the administration of anti-strumous 
remedies. The influence of rheumatism and gout in the production 
of discharges from the urethra has already been mentioned in con- 
nection with gonorrhoea. 

Symptoms. — In many cases of gleet, the discharge is the only 
symptom. There is an entire absence of pain in the part, of red- 
ness and tumefaction of the lips of the meatus, and of scalding in 
passing water. In some instances, however, the patient experiences 
a feeling of uneasiness in the penis or perineum, or an itching about 
the glans, or in the deeper portions of the canal, which may either 
be constant or attendant only upon the passage of the urine. Again, 
at the first act of micturition in the morning, the obstruction offered 
to the exit of the stream by the matter which has dried around the 
meatus, and glued its lips together, often gives rise to forcible dis- 
tension of the canal, and a sharp momentary pain in the urethra, 
which may be avoided by previously separating the lips of the 
orifice. 

The discharge in gleet varies in its character, quantity, and in 
the time of its appearance. In some cases it is evidently purulent, 
especially when the gleet has followed a recent attack of gonor- 
rhoea. In other instances, it is perfectly transparent, and, examined 
under the microscope, is found to consist of a clear fluid, containing 
epithelial cells and free nuclei, either with or without a few pus- 
globules. Again, coagulated masses, like the white of an egg, are 
sometimes forced from the canal. In some cases, the discharge is 
constant, and sufficiently copious to stain the linen; but in the 
majority it is perceptible only in the morning on rising. When 
dependent upon inflammation of the deeper portions of the canal, 



SYMPTOMS — PATHOLOGY. 85 

or of the prostate, it may only appear during the efforts of the 
patient at stool, or be mingled with the last drops of urine in mic- 
turition. The small amount of the discharge in most cases of gleet, 
and the frequency of this disease among soldiers, has given rise to 
the name, "goutte militaire," employed by the French. 

The symptoms of gleet now described are liable to be aggravated 
by any cause which produces urethral or vesical irritation. In 
other words, a gleet is readily transformed into a clap. A hearty 
meal, alcoholic stimulants, free sexual indulgence, violent exercise, 
a long ride, or exposure to sudden changes of temperature, may 
bring on a copious purulent discharge, attended by tumefaction of 
the parts, scalding in micturition, and all the symptoms of acute 
gonorrhoea. Only a few hours are required for this change to take 
place, and, hence, we may explain the sudden reappearance of some 
attacks of gonorrhoea — often supposed to be due to fresh contagion 
■ — when patients, too confident that they are well, are hasty in in- 
dulging in drink or coitus. 

Hunter, in his work on Venereal, states that " a gleet is perfectly 
innocent with respect to infection," and that in the relapses which 
so frequently occur, "the virus," in his opinion, "does not return." 
This statement, although often refuted, still finds place in many 
elementary works, which are in the hands of medical students. A 
doctrine more dangerous to the peace of families could scarcely be 
promulgated. It is, indeed, true, that men are occasionally met 
with who have for years suffered from gleet, and who have yet had 
frequent connection with their wives with impunity, but where 
contagion ceases and immunity begins, no one can tell; and even if 
we were able to pronounce a discharge of a certain degree of purity 
innocuous, we could not foresee the effect upon it of a few hours' 
sexual indulgence. It may at the present moment be wholly 
mucous, and entirely innocent of contagious properties, and yet a 
short time hence be purulent, and in the highest degree dangerous. 
The fact is, no one can pronounce sexual congress safe, so long as 
a urethral discharge exists, and in replying to the frequent ques- 
tions of patients on this point, the surgeon should not only avoid 
incurring the responsibility of allowing it, but do all in his power 
to dissuade from it. 

Pathology. — Our knowledge of the pathology of gleet is some- 
what imperfect, since the urethra is beyond the reach of direct 



86 GLEET. 

observation, and opportunities for making post-mortem examina- 
tions of persons affected with this disease are very rare. There 
can be no doubt, however, of the general truth of the law that, 
while the straight or anterior portion of the urethra is affected in 
gonorrhoea, the posterior and curved portion is the most frequent 
seat of gleet, as evidenced by the extension of the inflammation in 
many cases to the testicle, the uncomfortable sensations experienced 
by the patient in the perineum, and the difficulty of curing the dis- 
ease by means of injections, unless the fluid be made to enter the 
deeper portions of the canal ; moreover, after the spongy urethra 
has been freed of its discharge by pressure along the under surface 
of the penis, an additional quantity may generally be forced out 
from the bulbous and membranous portions by pressure upon the 
perineum. 

In the few post-mortem examinations which have been made of 
persons affected with urethral discharges, sufficient attention has 
not been paid to the duration of the disease nor to the symptoms 
during life. The most minute description of the pathological 
appearances of gonorrhoea and gleet is the one given by Kokitansky, 
who says : " We find the anatomical characters to be those belonging 
to catarrh generally ; in the acute stage there is, according to the 
violence of the process, redness, injection, tumefaction of the urethral 
mucous membrane, or secretion of puriform mucus ; in the chronic 
stage there is tumefaction of the mucous membrane, enlargement 
of the follicles, relaxation of the sinuses, and a white or colorless 
secretion. The inflammation is either uniformly diffused over the 
urethra, or is limited to one or more spots. The latter is especially 
the case in genuine gonorrhoea of the male urethra ; we here find 
not only the navicular fossa, but every point as far as the prostatic 
portion, and especially the vicinity of the bulb of the urethra liable 
to become the seat of the disease. When the gonorrhoea is very 
violent and obstinate, a small tubercular swelling, which results 
from the deposition of fibrous matter in the spongy tissue of the 
urethra, is found at these points." 1 

Mr. Thompson has found nearly the same appearances: "Ob- 
servation demonstrates that the two spots which suffer most from 
gonorrhoeal inflammation, are the fossa navicularis and the bulb ; I 
have had opportunities of observing this two or three times in the 
dead-house, on the bodies of patients who had been suffering from 

1 Pathological Anatomy, Sydenham Society's Translation, vol. ii. p. 233. 



PATHOLOGY — TREATMENT. 87 

gonorrhoea shortly before death. Unusual vascularity is found in 
the latter situation, particularly if the affection have been chronic, 
while the intermediate part appears comparatively very little 
affected. There is a preparation in the Museum of St. George's 
Hospital, which exhibits the urethra of a patient who died while 
suffering from gonorrhoea, in which an ulcer exists (the only one to 
be seen) in the commencement of the membranous portion." 1 It is 
impossible to determine whether the ulcer in the case referred to by 
Mr. Thompson was a chancre, or a superficial erosion such as is met 
with in balanitis ; it was probably the former, since gonorrhoeal 
inflammation rarely produces ulcerations involving the whole 
thickness of the mucous membrane and capable of detection in a 
preparation that has been preserved for a long time in spirit. 

The lacuna magna upon the superior wall of the fossa navicularis 
is probably, in some instances, the source of the discharge in gleet, 
since it is peculiarly exposed from its situation to participate in 
the inflammation of gonorrhoea, and its internal surface is not 
readily accessible to injections. Dr. Phillips states that he has 
succeeded in curing four obstinate cases of gleet by introducing a 
director along the upper surface of the urethra until its extremity 
entered the lacuna magna, and slitting up the wall of the follicle 
with a narrow bistoury. 

When the disease is situated in the deeper portions of the canal, 
we may sometimes determine its seat by the introduction of a 
bulbous pointed sound or bougie. The patient flinches when the 
affected part of the canal is reached, and the enlarged extremity of 
the instrument meets with slight obstruction from the thickened 
mucous membrane. 

It appears, therefore, that the pathological changes of gleet are 
similar to those met with in chronic inflammation of other mucous 
membranes, as the conjunctiva, tear passages, and the external 
meatus auditorius, and the extension of the inflammatory process 
to the membrane lining the follicles and the ducts which open into 
the deeper portions of the urethra, may account for the well-known 
persistency of the disease, which is almost proverbial. 

Treatment. — The treatment of gleet should be addressed to the 
general condition of the patient as well as to the local disease. It 
may be laid down as a rule to which there are but few exceptions, 

1 Stricture of trie Urethra, p. 84. 



88 GLEET. 

that in gleet the tone of the general health is more or less reduced. 
Not that all patients with gleet are necessarily weak and emaciated ; 
on the contrary, many appear to be robust and hearty ; but it is 
almost always the case that they are not capable of the same amount 
of exertion as formerly'; they are sensible that they have lost a 
portion of their animal vigor ; and the benefit of general hygienic 
measures and tonics in their treatment is unmistakable. The diet 
should be plain but substantial, consisting of fresh meat, vegetables, 
eggs, etc., to the exclusion of salt meats, cheese, and highly-seasoned 
articles ; and secretion from the skin should be promoted by means 
of frequent sponging or bathing. With regard to exercise, although 
a long walk or ride, especially when carried to fatigue, will be found 
to aggravate the discharge, yet when commenced with moderation, 
and gradually and steadily increased in proportion to the strength, 
it is found to be highly beneficial. Healthy exercise of the mind 
is no less important than that of the body, and the attention of the 
patient should be distracted as much as possible from his disease, 
and all books and associations calculated to excite the passions be 
avoided. The bowels should be opened daily, if possible by selecting 
such articles of food as are laxative, and by regularity in the hour 
of going to the closet, or, if required, by the administration of 
medicine. One of the following pills taken at bedtime, will usually 
insure a free stool in the morning. 

R. Strychnise gr. ss. 

Pil. colocynth. comp. 5ss. 
M. 
Divide into thirty pills. 

In the tincture of the chloride of iron, we have a most valuable 
combination of a tonic and an astringent ; which, in most cases of 
disease of the generative organs in the male and female, is unequalled 
by any of the more modern and elegant preparations of this mineral. 
It may be given in doses of from five to twenty drops, largely 
diluted with water, three times a day, directly after meals. If the 
dose be properly graduated, it less frequently excites headache in 
the male than the female ; should this unpleasant symptom occur, 
iron reduced by hydrogen may be substituted for it, in doses of 
three grains, three times a day. "Where the constitutional debility 
is marked, the union of quinine with iron may be desirable, as in 
the following : — 



TREATMENT. 89 

R. Ferri et quinise citratis ^j-ij. 
Aquae gj. 

Syrupi limonis ^ij. 
M. 
A teaspoonful after each meal. 

I£. Tincturas cantharidis 5j« 

Quinise sulphatis sjss. 

Tincture ferri chloridi 5ij« 

Acidi sulphurici diluti xxx. 

Aquae destillatae 5viij. 
M. 
One ounce three times a day. (Childs.) 

Other salts of iron, as the tartrate of iron and potassa, or the 
pyrophosphate of iron, may be substituted for the citrate, in the 
first of the above prescriptions. 

In the administration of iron I have always found a rule laid 
down by Trousseau, a good one, viz., not to stop the medicine 
suddenly ; after the object for which it is administered has been 
attained, it may be omitted for a fortnight, when it should again 
be resumed for a few weeks ; in this way its effect is rendered much 
more permanent. 

With patients of a strumous diathesis, cod-liver oil, the syrup of 
the phosphates, or Blancard's pills of iodide of iron, may often be 
used with advantage. I have found that the iodide of potassium 
has a tendency to increase the discharge from the urethra, as it 
often does the secretion from other mucous membranes, and I do 
not therefore administer it. This effect of the iodide may frequently 
be observed, when we are giving it for tertiary syphilis to patients, 
who, at the same time, are affected with gleet. 

From what has already been said of copaiba and cubebs, it is 
evident that but little good can be expected from their administra- 
tion in cases of chronic urethral discharge. Moreover, most pa- 
tients, whose disease has arrived at this stage, have already taken 
them ad nauseam for the preceding gonorrhoea ; hence, we are rarely 
called upon to administer them in pure gleet. In those cases, how- 
ever, in which the gleet has relapsed into a clap, they may be given 
with benefit, especially when combined with a tonic, as in the dragees 
of copaiba, cubebs, and citrate of iron ; in Meot's pills, the formula 
for which has already been given ; and as in the following pre- 
scription :— 



90 GLEET. 

I£. Copaibse §ss. 

Tincturse cantharidis |ss. 

Tincturse ferri chloridi §j. 
M. 
Dose. — Thirty drops three times a day. 

The reader will observe that the tincture of cantharides is an 
ingredient of several of the above prescriptions. Experience has 
shown that this drug exerts a decidedly curative action in many 
cases of gleet, and in gonorrhoea also, in the chronic stage. It is a 
favorite remedy with the homoeopaths, in doses of a drop of the 
tincture every few hours, in the acute stage of clap, and is con- 
sidered by them to be indicated by scalding in micturition, chordee, 
and a greenish or bloody discharge. I have used it, however, only 
in the chronic stage. The tincture may be given in doses of three 
or five drops three times a day, or it may be combined with iron, 
as follows : — 

fy. Tincturse cantharidis 5^ 

Tincturse ferri chloridi 5^j. 
M. 
Ten drops in water, three times a day. 

In some cases of gleet there is considerable irritability of the 
neck of the bladder, as shown by a frequent desire to pass the urine 
and unpleasant sensations in the perineum. In these cases benefit 
will be derived from the administration of the salts of potash, com- 
bined with hyoscyamus, as in the prescriptions already given when 
speaking of the acute stage of gonorrhoea. Canada balsam is also 
an excellent remedy under these circivmstances. 

]£. Ahietis balsamese gij. 

Div. in pil. No. xxiv. 
Two, three times a day. 

Bougies. — In all cases of gleet, the urethra should be carefully 
examined with a full sized bougie or sound, in order to detect the 
presence of stricture ; and if the slightest contraction be discovered, 
it should at once receive appropriate treatment, since upon its 
removal will probably depend the cure of the discharge. Dr. 
Charles Phillips, whose name is little known to the American pub- 
lic, but who in Paris has acquired an enviable reputation in diseases 
of the genito-urinary organs, states that gleet is almost invariably 
dependent upon slight stricture, which may be detected by means 
of bulbous-pointed and knotted bougies, but which is frequently 



BOUGIES. 91 

overlooked from the want of careful exploration with proper instru- 
ments. 1 

Whatever may be the truth of this statement, which, to say the 
least, requires confirmation, the frequent passage and retention of 
bougies is one of the best means known for the treatment of gleet, 
even when no stricture can be discovered by the ordinary mode of 
examination. The manner in which bougies effect a cure of chronic 
urethral discharges is somewhat obscure, but is probably to be ex- 
plained on the ground that they distend the canal, expose lacunae in 
which matter would otherwise lodge, and separate for a time the 
diseased surfaces ; or, again, they may serve to stimulate the vessels 
of the part, and thus change their action. 

Bougies tapering towards the extremity and terminating in an 
olive-shaped point, are best adapted for the purpose. They are 
introduced easily and with little inconvenience to the patient, and 
the contraction near their point facilitates the introduction of medi- 
cated ointments into the deeper portions of the canal. The instru- 
ment should be large enough fully to distend the canal but not to 
stretch it, and should be smeared with cerate, lard, olive or castor 
oil, or glycerin. The bladder should previously be emptied and 
the patient placed in the recumbent posture. However gently it 
may be introduced, the first passage of a bougie usually excites a 
more or less disagreeable sensation, which sometimes gives rise to 
syncope, and which generally renders it advisable to withdraw the 
instrument in a few minutes ; but after two or three insertions it 
ceases to give annoyance, and may be retained for half an hour or 
an hour. 

It sometimes happens that the bougie aggravates the discharge, 
and revives the acute inflammation which has for a time disap- 
peared. In such cases it is best to suspend the treatment and resort 
to injections, which will often effect a permanent cure. This ag- 
gravation of the symptoms, however, according to my experience, 
takes place in a minority of cases only. 

With this exception, the passage of the bougie may be repeated 
every second or third clay at first, and afterwards every day, or in 
some instances as often as twice a day. The length of time requi- 
site for a cure by means of bougies varies in different cases. As 
examples of their successful employment I may mention one case 

1 Traite des Maladies des Voies Urinaires, Paris, 1850, p. 33. 



92 GLEET. 

recently under my care, a gleet of four years standing, which was 
treated with the tincture of the chloride of iron internally, and the 
introduction of bougies every second day, and in which a cure was 
effected in two weeks. In another case, a gleet of nine months, the 
discharge disappeared in three weeks under the use of the same 
means. Other cases of a like character might be mentioned, but 
such satisfactory results cannot by any means be expected in every 
instance. In many, this treatment must be continued for several 
months, or other measures, as injections and blisters, be resorted to. 
Bougies may be medicated in various ways. Calomel rubbed up 
with sufficient glycerin or oil to cover it, forms a very cleanly and 
excellent mixture with which to anoint the bougie, and I think 
materially assists the curative action. Mercurial ointment may 
also be used, either alone or combined with extract of belladonna, 
the latter being added in case the urethra is irritable. 

I£. Unguenti hydrargyri £ss. 
Extracti belladonnse 5ss. 
M. 

For the purpose of stimulating the mucous membrane, we may 
employ the diluted ointment of red oxide of mercury, or an oint- 
ment containing a few grains of nitrate of silver, but such applica- 
tions should not be continued for any length of time, lest they keep 
up the discharge. 

I£. Ung. hydrarg. oxidi rubri gj. 

Adipis 5iij. 
M. 

R. Argenti nitratis gr. v-x. 

Adipis aj. 
M. 

Injections. — Injections have been so fully discussed in the preced- 
ing chapter, that little remains at present to be said of their com- 
position, or the ordinary mode of their administration. 

In gleet as in gonorrhoea, weak solutions of the sulphate or 
acetate of zinc (containing from two to three grains to the ounce of 
water) are in most instances to be preferred ; and the injection 
should be made to permeate the urethra as deeply as possible, in 
order that it may be applied to the whole extent of the affected 
surface, but care should be taken not to distend the canal with too 
much force, the sensations of the patient being the best indication 
when a sufficient amount has been employed. So far as inflamma- 



INJECTIONS. 93 

tion of the testicle and prostate have any connection with the use 
of injections, I believe they are more frequently due to violent 
manipulation than to the irritant character or strength of the solu- 
tion. Hence, injections should always be used with gentleness, 
while at the same time the canal should be entirely filled, that none 
of the folds, into which the urethral walls are naturally thrown ex- 
cept during the passage of the urine, may escape coming in contact 
with the astringent fluid. With this precaution, a weak injection 
may be employed to advantage every two or three hours ; a degree 
of frequency which will often prove successful when a less degree 
has failed. 

In addition to the formulae for injections given in the chapter 
upon gonorrhoea, the following may be added : — 

fy. Hydrargyri bichloridi gr. j. 
Aquae §viij-xij. 

M. 

I£. Gallae 3j. 

Aluminis £)ij. 

Aquae ^viij. 
M. 

I£. Acidi nitrici gtt. xvj-xl. 
Aquae ^viij. 

I have recently employed with very satisfactory results the solu- 
tion of persulphate of iron prepared by Dr. Squibb, as in the fol- 
lowing: — 

I£. Liq. ferri persulphatis (Squibb) gss. 

Aquae gvj. 
M. 

The strength of the above solution may, in some instances, be 
increased. 

Eicord advises solutions containing iodine in scrofulous subjects, 
and although the injection of this mineral into the urethra cannot 
be supposed to affect the constitutional diathesis, yet it may exert 
a beneficial action upon the mucous membrane as when applied to 
the fauces. 

~fy. Tinct. iodinii gtt. viij. 

Aquae ^f viij. 
M. (Ricord.) 

I£. Ferri iodidi gr. viij. 

Aquae ^viij. 
M. (Ricord.) 



94 GLEET. 

I will here repeat a suggestion previously given, that the use of 
any medicated injection, and especially one containing insoluble 
ingredients, will prevent even a sound urethra from exhibiting its 
normal dryness. Without due caution, therefore, a patient may go 
on injecting long after his disease is cured. Hence, after the dis- 
charge has for some time been reduced to a very minute quantity, 
and especially if it appear to consist of little more than the insolu- 
ble deposit of the solution, the injection should be omitted for a few 
days, in order that the exact condition of the urethra may be de- 
termined ; or, again, it may be administered only once in the twenty- 
four hours, selecting for the purpose the early part of the day, and 
the appearance of the meatus the following morning will indicate 
what progress has been made towards a cure. 

Substitutive medication is sometimes employed in gleet as in the 
abortive treatment of the first stage of gonorrhoea. Thus, highly 
irritant or caustic injections are used with the intention of exciting 
acute inflammation, upon the subsidence of which the chronic 
affection may perhaps disappear. Nature accomplishes the same 
result in the same manner, when, as sometimes happens, after the 
cure of a fresh attack of gonorrhoea no traces remain of a preceding 
gleet. Substitutive treatment, however, is less successful in gleet 
than in the early stage of gonorrhoea, since the seat of the disease 
is less accessible and the mucous membrane more deeply affected ; 
moreover, it is less safe, since an irritant injection extended to the 
deeper portions of the canal is more liable to induce swelled 
testicle than when limited to the fossa navicularis. 

Either nitrate of silver or chloride of zinc is most frequently 
employed in the substitutive treatment of gleet, and, as in the 
abortive treatment of gonorrhoea, the solution may be a strong 
one and injected but once, or weak and repeated a number of times. 
For instance, the surgeon may thoroughly and once for all inject 
with his own hands a solution of ten or fifteen grains of nitrate of 
silver, or five grains of the chloride of zinc to the ounce of water ; 
or a weaker solution of either (from one to five grains of the 
nitrate, and from half a grain to two grains of the chloride) may 
be injected by the patient several times a day until the discharge 
becomes copious and purulent, when the injections should be 
suspended until their effect upon the gleet can be determined. 

Sometimes, as previously stated, the pain excited in a certain 
portion of the urethra by a bulbous pointed bougie and the slight 



DEEP URETHRAL INJECTIONS. VO 

obstruction presented by the thickened mucous membrane, will 
indicate the probable source of a gleety discharge ; and in such 
instances, having first measured its distance from the meatus, 
the affected surface may be cauterized with Lallemand's porte- 
caustique. 

Deep Urethral Injections. — In the ordinary method of injecting 
the male urethra, it is impossible to make the fluid pass through 
the whole extent of the canal into the bladder. After a certain 
portion (about half an ounce) of the contents of the syringe has 
been injected, the remainder escapes above the piston, or, however 
tightly the glans may be compressed around the point of the in- 
strument, flows from the meatus. The obstruction to the entrance 
of the fluid is due to the contraction of muscular fibres (the com- 
pressor urethras muscle) which surround the membranous portion 
and serve as a sphincter to the urinary canal ;* and this is the 
posterior limit of the application of the fluid to the urethral walls 
by the more common method of injecting. In order to reach the 
deeper portions of the canal, which are involved in many cases of 
gleet, it becomes necessar}- to resort to injections through a catheter, 
or by means of the "urethral syringe with extra long pipe," manu- 
factured by the American Hard Rubber Company. 

The length of the urethra should be measured by introducing a 
catheter and marking the point in contact with the meatus when 
the urine first commences to flow ; upon withdrawing the instru- 
ment the distance between its eye and the mark upon the stem will 
be the measurement required. On again introducing the catheter 
for the purpose of injecting (the patient having first passed his 
water), it is an easy matter to carry its point within half an inch of 
the vesical neck without entering the bladder, when the fluid may 
be thrown in by means of a syringe as the instrument is slowly 
withdrawn. If the catheter be sufficiently large to moderately 
distend the canal, none of the injection will escape from the 
meatus so long as the eye of the instrument is in the prostatic or 
membranous portion of the urethra, since the contraction of the 
same muscle which prevents the entrance of fluid from without, 
also prevents its exit from within, and obliges it to flow backwards 
towards the bladder ; hence we may, if we choose, limit the appli- 
cation of the injected fluid to the deeper portions of the canal 

1 See the section on the Anatomy of the Urethra in the chapter on Stricture. 



96 GLEET. 

exclusively, and the pain excited will be found to be less than 
when a solution of the same strength is thrown into the external 
portion, since the urethra, like other mucous passages, is most 
sensitive near its outlet. The chief disagreeable sensation follow- 
ing an injection thus confined to the portion of the urethra lying 
between the compressor urethras muscle and the neck of the 
bladder, is an urgent desire to pass water, which, however, should 
be resisted as long as possible, that the fluid may have time to act 
upon the urethral walls before it is washed away or neutralized by 
the urine. During the succeeding twenty -four hours, micturition 
is somewhat more frequent than usual, but is not particularly 
painful ; and the discharge is slightly increased for a day or two. 

The efficacy and safety of these injections in affections of the 
deeper-seated portions of the urethra is attested by MM. Diday 1 and 
Bonnet, of Lyons, Mr. Langston Parker, 2 of Birmingham, and my 
own experience. The same formulae may be employed that have 
been recommended for injections by the more common method, 
and the application may be repeated once or twice a week. 

Blisters. — Blisters were long ago recommended for the cure of 
obstinate cases of gleet, but had almost fallen into disuse, when 
they were revived by Mr. Milton, in his work on the treatment of 
gonorrhoea. This author speaks of them in the following terms : 
"I have seen two blisters, with a mild injection or two, at once cure 
a clap which had defied the most energetic treatment ; and as I 
never found a case which resisted blistering and injections together, that 
was not complicated with stricture or affection of the testicle, lam slowly 
arriving at the conviction, that every case of clap or gleet, however ob- 
stinate, may, if uncomplicated, be cured by blistering, singly or com- 
bined."* It is to be feared, however, that this remedy has proved 
less successful in the hands of other surgeons than in Mr. Milton's. 
Eecent writers who have spoken favorably of them, appear to have 
done so chiefly on Mr. Milton's authority ; others, as Mr. Langston 
Parker, have given their testimony decidedly against them, and in 

1 Des Injections circonscrites a la partie profonde de l'uretre, de leur mode d'exe- 
cution et de leur efficacite curative ; Annuaire de la Syphilis, annee 1858, p. 61. 
Diday's method of employing deep urethral injections has been followed in the 
above description. 

2 Syphilitic Diseases, page 82. Mr. Parker injects the fluid into the bladder, 
lets it remain for a few minutes, and desires the patient to force it out. This 
method is not so good as the one above recommended. 

3 Milton on Gonorrhoea, p. 90. The Italics are in the original. 



SEPARATION OF THE AFFECTED SURFACES. 97 

my own practice they have not been attended with such success as 
to lead me to prefer them to other and less disagreeable modes of 
treatment. Still, they may be worthy of a trial in obstinate cases 
which have resisted the use of bougies and injections. 

The manner of applying them is of considerable importance. 
The hair should be shortened around the root of the penis, and a 
piece of paper be wrapped around the organ, and cut in such a 
manner as to form a pattern of its surface from the pubis to within 
half an inch of its extremity. The blister, corresponding in shape 
and size to the pattern, should be applied to the penis, and tied or 
fastened in its place, that it may not slip, and coming in contact 
with the scrotum, produce a troublesome sore. It should not be 
retained longer than two hours, during which the patient must 
remain quiet. The morning is the best time for its application, 
since, if applied at night, it is likely to prevent sleep. On remov- 
ing- it, the surface is found to be reddened, but not vesicated, un- 
less, perhaps, at a few points ; and the penis should now be covered 
with a rag spread with simple cerate, and be protected from friction 
by an external layer of cotton wadding. 

On examining the parts after a few hours, it will be found that 
numerous bullae have formed on the surface, which at first appeared 
to be only reddened. These may be pricked, and the serum which 
they contain evacuated, but the epidermis should be carefully pre- 
served. I have sometimes found the extremity of the prepuce 
beyond the site of the blister, puffed out with an effusion into its 
cellular tissue, which may be left to take care of itself, or, if exces- 
sive, be evacuated by a few punctures with a lancet. 

Cantharidal collodion is a more convenient application than the 
unguentum lyttae, but its effect cannot be limited like that of the 
latter, which should therefore be preferred. When applied for a 
few hours only, I can confirm Mr. Milton's statement, that blisters 
do not excite severe pain, nor produce a troublesome sore. The 
first effect of their application is to increase the urethral discharge, 
which can only be expected to be benefited in the course of five or 
six days. The blister may be repeated at the end of a week, if any* 
discharge still remain. The perineum may be blistered in a simi- 
lar manner, but this will require the patient to be kept in bed until 
the vesicated surface has healed. 

Separation of the Affected Surfaces. — Contact of the diseased sur- 
faces doubtless assists in keeping up the discharge in gleet, as it is 
7 



yy GLEET. 

well known to do in balanitis. Hence it has been proposed, by 
means of a probe and a gum-elastic bougie open at the extremity, 
to introduce a strip of lint, either dry or soaked in some astringent 
fluid, within the urethra, and thus maintain its walls apart, renew- 
ing the application after each passage of the urine. This method, 
in which I have had no experience, has been successful in some 
instances, but is very troublesome and inconvenient, and would 
appear to be attended with danger of the lint slipping entirely into 
the urethra, and entering the bladder. Civiale mentions a case in 
which this accident occurred, but does not give the ultimate result. 1 
Mr. Milton 2 states that it has happened to him in several instances, 
and that the lint has always found its own way out, but the danger 
of its retention is too great to be incurred. 

Finally, in obstinate cases of gleet in which the discharge ap- 
pears to come from the anterior portion of the urethra, laying open 
the lacuna magna, as recommended by Dr. Phillips, is worthy of a 
trial. 3 

1 Maladies des Organes Genito-urinaires, vol. i. p. 444. 

2 On Gonorrhoea, p. 31. 

3 See page 87. 



BALANITIS— CAUSES. 99 



CHAPTER III. 

BALANITIS. 

If the prepuce be retracted, a mucous surface of considerable 
extent is exposed, a portion of winch covers the glans penis, and 
the remainder consists of the internal reflection of the prepuce. 
This surface may be the seat of inflammation, similar to that which 
has been described as affecting the urethra. If the disease be con- 
fined, as it sometimes is, to the membrane covering the glans, it 
should, strictly speaking, be called balanitis ; if to the internal sur- 
face of the prepuce, posthitis, and if it involve both, balano-posthi- 
tis ; all these varieties, however, for the sake of convenience, are 
commonly included under the one name, balanitis. Gonorrhoea 
spuria, balano-preputial gonorrhoea and external blennorrhagia are 
other terms by which it is sometimes known. 

Causes. — Men in whom the prepuce is very long, or who are 
affected with congenital phymosis, are peculiarly exposed to bala- 
nitis, since the mucous membrane covering the glans, and lining 
the prepuce, is maintained in so sensitive a condition, from its want 
of exposure to the air and friction, that inflammation is readily set 
up by the least cause of irritation. In persons with congenital phy- 
mosis, the mere collection of sebaceous matter,- the removal of 
which is prevented by the occlusion of the preputial orifice, is suf- 
ficient to give rise to balanitis ; and I have known of several in- 
stances in which, from inattention, the discharge was supposed to 
come from the urethra, and was mistaken for gonorrhoea. The 
diagnosis can readily be made by exposing and wiping the meatus, 
and then observing whether upon pressure the matter comes from 
the urethra, or the balano-preputial fold. 

In general, the exciting causes of balanitis are the same as those 
of urethral gonorrhoea. Thus it may arise from exposure to gonor- 
rhoea! or leucorrhoeal discharges, or from intercourse about the 



100 BALANITIS. 

time of the menstrual period ; and, even more frequently than gonor- 
rhoea, from coitus with a healthy woman, particularly under cir- 
cumstances of special excitement, from violence, masturbation, 
excessive exercise, the want of cleanliness, errors in diet, and atmos- 
pheric influences. To these should also be added the presence of 
a chancre, vegetation, or an eruption dependent upon syphilis or 
other causes, upon the mucous membrane of the glans or prepuce. 

Symptoms. — The symptoms of balanitis are tenderness of the 
extremity of the penis, an itching sensation beneath the prepuce, 
and scalding during micturition if the urine comes in contact with 
the affected surface. The inflamed mucous membrane is sensitive 
on pressure, reddened, and often denuded of epithelium in irregular 
patches, which are of a darker red than the surrounding surface 
where the epithelium is but partially detached. These superficial 
excoriations are generally multiple, and are similar to the ulcera- 
tions frequently met with upon the cervix uteri. The affected 
surface secretes a muco-purulent fluid, varying in quantity and 
consistency, as in gonorrhoea. If phymosis exist and the preputial 
orifice be so contracted as not to afford free exit to the discharge, 
the matter may collect at the base of the glans and form an abscess. 
An effusion of serum takes place in the cellular tissue of the pre- 
puce, rendering it more or less oedematous, and sometimes occasion- 
ing accidental phymosis. The general system sympathizes but little 
with the local affection, which is in most cases of short duration, 
and very amenable to treatment. The inguinal ganglia may, in 
rare instances, become slightly enlarged and sensitive, but they 
never suppurate. 

One attack of balanitis predisposes to another. Men with a long 
prepuce or congenital phymosis, are often met with who have lived 
thirty or forty years without suffering inconvenience from their 
malformation, but who, after one attack of balanitis, are constantly 
subject to others, following intercourse with the most healthy 
woman, or even mere imprudence in diet. 

Teeatment. — When the prepuce can be retracted, the treatment 
of balanitis is exceedingly simple. All that is necessary, in most 
cases, is to free the parts from any collection of matter by gently 
washing them with tepid water, and then to cut a piece of lint or 
soft linen into pieces about an inch square, and laying them upon 



TREATMENT. 101 

the glans with their upper margin well up in the corona, to draw 
the prepuce over them. In this manner the inflamed surfaces are 
isolated from each other, and speedily take on a more healthy 
action. The frequency with which this application should be 
repeated depends upon the copiousness of the discharge ; generally 
from two to four times in the twenty-four hours is sufficient, and a 
cure is usually attained in a few days or a week. In severe cases, 
however, other measures than those mentioned may be desirable. 
If the surface be excoriated, it is well to pencil it over lightly with 
a crayon of nitrate of silver, or to apply a solution of this salt, of 
the strength of a drachm to the ounce of water. Again, instead of 
using the lint dry, it may be moistened in either of the following 
mixtures : — 

]£. Liquoris plumbi diacetatis &j. ty.. Liquoris sodae chlorinatae 3iij. 

Aquae ^ij. Aquae Jjv. 

M. M. 

]£. Acidi tarmici ^j. I£. Extracti opii 9j. 

Glycerin §j. Zinci sulphatis gr. vj. 

M. Glycerin Jj. 

Aquae |ij. 
M. 

When phymosis, either congenital or acquired, exists, the parts 
are less accessible to treatment. In this case the nozzle of a syringe 
holding several ounces and filled with tepid water, should gently 
be inserted between the glans and prepuce, and its contents be 
discharged into this cavity, in order to free it from all collection of 
matter. A few drachms of a solution of nitrate of silver, or of one 
of the lotions just mentioned, may then be thrown up, and this 
should be repeated several times in the course of the day. In these 
cases, Mr. Langston Parker highly recommends the following pre- 
paration, introduced between the glans and prepuce by means of a 
camel's-hair pencil : — 

R;. Cerati simplicis, vel mellis, 

Olei olivae, aa § j . 

Hydrargyri chloridi gss. 

Extracti opii 3J. 
M. 

If balanitis be attended by much infiltration into the cellular 
tissue of the prepuce, the fluid should be evacuated by several 
punctures with a lancet. * If the patient can keep his bed, the penis 
may also be enveloped in a single thickness of linen, wet with cold 



102 BALANITIS. 

water or diluted Goulard's extract, and exposed to the air. If, 
however, he continues his daily occupation, no benefit can be ex- 
pected from such applications, which, when confined by the clothes, 
act like poultices, and favor rather than prevent oedema. In all 
cases the cure of balanitis will be accelerated, if the patient be kept 
quiet and the parts elevated. When this disease is dependent upon 
the presence of a chancre, secondary eruptions or vegetations, these 
should receive their appropriate treatment. 

With persons who have repeated attacks of balanitis it becomes 
an important object to take measures to prevent them. To accom- 
plish this the strictest cleanliness should be enjoined. The parts 
should twice a day be cleansed of all accumulation of their natural 
secretion, and afterwards moistened with an astringent lotion, as a 
mixture of equal parts of brandy and water with the addition of 
alum, a solution of tannin, or any of the astringent washes already 
mentioned. It is also desirable to attend to the digestive functions, 
and to regulate the diet. The influence of a long prepuce in pro- 
ducing relapses of this disease has already been referred to. I have 
sometimes succeeded in remedying this malformation by directing 
the patient to keep his prepuce constantly retracted by means of a 
narrow bandage applied around the penis, posterior to the glans. 
If this be worn for a few weeks, the prepuce will often remain 
retracted ^without further assistance, and the mucous surface of the 
glans becomes hardened by exposure and friction. If this attempt 
prove unsuccessful, the superfluous integument should be removed 
by circumcision. 



PHYMOSIS. 103 



CHAPTER IV. 

PHYMOSIS. 

The term Phymosis is applied to that condition of the penis in 
which it is impossible to retract the prepuce behind the glans. 

In the majority of cases phymosis is a congenital malformation 
due to unnatural narrowness of the preputial orifice, and may be 
associated with adhesions, varying in position and extent between 
the glans and its covering. A remarkable instance of this kind is 
recorded in the Surgical Eegister of the N. Y. Hospital: Joseph 
Smith, of Prussia, aged 49, was admitted into this institution Oct. 
19, 1832, with congenital phymosis. Dr. Stevens removed the free 
portion of the prepuce, which was found to be attached to the. mar- 
gin of the meatus instead of the base of the glans, and formed a 
tubular prolongation of the urethra nearly an inch in length. 

Congenital phymosis is a source not only of great inconvenience 
to the subject of it, but of increased exposure to venereal diseases 
in promiscuous intercourse, and is sometimes the cause of serious 
disturbance in the genito-urinary and nervous systems. 

Mr. Jonathan Hutchinson 1 has shown by statistics that syphilis 
is much less common among Jews than among Christians, probably 
on account of the practice of circumcision among the former. At the 
Metropolitan Free Hospital, situated in the Jews' quarter, London, 
in 1854, the proportion of Jews to Christians among the out-patients 
was nearly one to three ; yet the ratio of cases of syphilis in the 
former to those in the latter was only one to fifteen ; and that this 
difference was not due to their superior chastity was evident from 
the fact that the Jews furnished nearly half the cases of gonorrhoea 
that were treated during the same period. Mr. Hutchinson's ob- 
servations also lead him to believe that hereditary syphilis is much 
rarer among the children of Jews than Christians ; and the experi- 

1 Medical Times and Gazette, Dec. 1, 1855. 



104 PHYMOSIS. 

ence of most surgeons will confirm the fact that persons with a 
long prepuce, and especially those affected with congenital phymo- 
sis, are peculiarly subject to venereal diseases. 

The size of the preputial orifice in congenital phymosis varies in 
different cases. In some, it is large enough to permit of the partial 
exposure of the glans and the removal of the natural secretion of 
the part, at least with the assistance of a syringe and injections of 
warm water; while in others, it is so contracted that it is difficult 
or even impossible to uncover the meatus; whence it happens that 
the entrance of the urine at each act of micturition beneath the 
prepuce, and the collection of sebaceous matter, maintain a constant 
state of irritation and even chronic inflammation, to which most of 
the adhesions met with between the opposed surfaces are undoubt- 
edly attributable. 

Daily observation proves that congenital phymosis is not incon- 
sistent with a state of perfect health ; and yet when we reflect upon 
the sympathy existing between different portions of the genito- 
urinary apparatus, and between the latter and other organs, we 
might reasonably expect to meet with at least occasional instances 
in which irritation of the head of the penis due to this cause gives 
rise to disturbance in other parts of the body. These anticipations 
are realized in practice ; but, according to Fleury, 1 who has ably 
investigated this subject, such disturbance is to be attributed more 
to the extreme sensitiveness of the balano-preputial membrane con- 
stantly protected from friction and exposure to the air, than to the 
irritation of collections of sebaceous matter ; since it is often present 
even when the condition of the parts admits of the most perfect 
cleanliness. 

Among the symptoms which have been ascribed to congenital 
phymosis are : balanitis, constant itching and even pain at the head 
of the penis, inordinate excitability of the genital organs, frequent 
erections, erotic dreams, seminal emissions, imperfect development 
of the penis and testicles, incomplete and painful ejaculation of the 
sperm, vesical tenesmus, incontinence of urine, gastralgia, neural- 
gias, and general lassitude and prostration. Probably no one will 
be disposed to call in question the occasional connection between 
the milder of the above affections and phymosis. With regard to 
the others, some doubts might be legitimately entertained, were it 

1 Gaz. des Hdp., Oct. 30, 1851. 



TKEATMENT. 105 

not for the circumstantial report of the symptoms, and the fact 
that simple excision of the elongated prepuce has in most cases 
brought complete and permanent relief. 1 

Accidental phymosis may depend upon any cause enlarging the 
glans penis to such an extent that it will not pass through the pre- 
putial orifice, or occasioning such an amount of thickening or con- 
traction of the prepuce that it cannot be retracted; in other words, 
the seat of the difficulty may be either in the glans or its covering. 

In some cases the obstruction is simply mechanical, as from vege- 
tations within the balano-preputial fold, the induration surrounding 
an infecting chancre, or the cicatrization of any primary sore situ- 
ated upon the margin of the prepuce. 

More frequently it originates in inflammatory action, as idio- 
pathic balanitis or posthitis, or the same affections excited by the 
presence of chancres, secondary eruptions, vegetations, etc., either 
of which may occasion swelling of the glans or infiltration in the 
lax cellular tissue of the prepuce. 

There is still another cause of phymosis which, strictly speaking, 
cannot be included among those just mentioned; I refer to a 
peculiar thickening of the mucous membrane and submucous 
tissue, observed both in men and women after the cicatrization of 
a chancre, and which consists neither in specific induration nor 
oedema, but in hypertrophy of the normal tissues of the organ. 
Grosselin believes that this effect is peculiar to primary sores, and 
ranks it among the consecutive symptoms of syphilis. It is most 
frequently found in the labia minora in women, and in the prepuce 
in men. In the latter the envelope of the glans may become so 
thickened that its retraction may be very difficult and give rise to 
fissures of the preputial orifice, or may be quite impossible. 

Tkeatment. — In congenital phymosis attended by any of the 
unpleasant effects alluded to at the commencement of this chapter, 
circumcision is the only sure means of relief; but if, from any 
cause, an operation be impracticable, the patient should be directed 
at each act of micturition to expose the meatus as perfectly as 

1 Fleury's observations have been fully confirmed by Borelli {Maladies genito- 
vesicales, Gaz. des Hop., Dec. 1851) ; Anagnostaxis relates a cure of amblyopia 
by excision of the prepuce {Rev. de Th r 'r. M?d.-Chir., No. 4, 1860) ; and Trousseau 
one of incontinence of urine by the same operation {Gaz. des Hop., No. 9, 1860). 



106 PHYMOSIS. 

possible in order to prevent the retention of the urine beneath the 
prepuce. 

In accidental phymosis, the rule is to avoid an operation if pos- 
sible, unless congenital phymosis has previously existed ; but when 
due to vegetations beneath the prepuce, or to contraction of the 
preputial orifice from the cicatrix of a chancre which has entirely 
healed, an operation may be necessary to gain access to the abnormal 
growths or to restore the opening of the prepuce to its original 
size. 

Phymosis dependent upon a large mass of specific induration, of 
which I have met with several instances, disappears under the 
internal administration of mercurials. 

An operation should, if possible, be avoided or deferred when 
the phymosis is due to acute inflammation, which may in most 
cases be subdued by rest in the horizontal posture, low diet, ca- 
thartics, leeches to the groin or perineum (not upon the prepuce), 
a lead and opium wash, and, if it be certain that no chancre is 
present, by scarifications; but if gangrene threaten, delay is no 
longer justifiable. 

In some instances, we are certain that a chancre is concealed 
between the prepuce and glans, where it may have been seen either 
by the patient or surgeon before the phymosis supervened; in 
others, its existence is highly probable, from the fact that the patient 
has been exposed in promiscuous intercourse. Now the mere 
suspicion of a chancre within the hidden folds of mucous mem- 
brane is sufficient to induce great caution in resorting to an ope- 
ration which may be followed by inoculation of the edges of the 
wound. It is indeed true, that if the primary sore be of the infect- 
ing species, auto-inoculation will not be likely to take place ; but the 
chancre may be of the mixed variety, or there may be both a true 
chancre and a chancroid ; hence the fact that a mass of induration . 
can be felt beneath the prepuce is not sufficient of itself to justify 
an operation. A case in point has fallen under my own observation : 
A medical friend was called to treat a case of phymosis dependent 
upon a chancre, surrounded by a cartilaginous mass of induration 
which could be felt beneath the prepuce. Eelying upon the fact 
that an infecting chancre cannot be inoculated upon the person 
bearing it, he resorted to an operation ; in a few days the edges of 
the wound assumed the appearance of a soft chancre. The original 
chancre was undoubtedly of the mixed variety. 



CIRCUMCISION. 107 

Under some circumstances, however, and especially with gan- 
grene threatening, an operation cannot be avoided ; but the incisions 
should be carefully protected from contact with the virus, and, if 
inoculated, should be cauterized with nitric acid. 

The thickening of the substance of the prepuce, already described 
as a sequela of primary sores, is rarely so great as to produce com- . 
plete phymosis ; but the difficulty attending the exposure of the 
glans and the frequent rents which the act occasions, often justify 
the removal of the hypertrophied tissues. 

Circumcision. — Partial operations for phymosis, as, for instance, 
slitting up the prepuce along the dorsum, or excision of a triangular 
portion, often fail to afford permanent relief, and leave the organ in 
a misshapen condition. The purposes of elegance and utility can 
best be subserved by circumcision. 

Before describing this operation, let me remind the student that 
the prepuce is composed of two layers, separated by cellular tissue 
of such lax texture as to admit of an almost indefinite amount of 
motion between them. The internal or mucous layer is firmly 
attached to the penis posterior to the corona glandis, and hence is 
incapable of being drawn forwards to any great extent in front of 
the glans. The external or integumental layer, on the contrary, is 
continuous with the flaccid skin of the body of the penis, and may 
be elongated almost indefinitely ; its anterior portion doubling in 
upon itself as the posterior is drawn forwards. It follows from 
this anatomical arrangement, that a section of the prepuce in front 
of the glans can only include the integumental together with an 
insignificant portion of the mucous layer. 

Of the various methods of performing circumcision recom- 
mended by different authors, I prefer the following : — 

The patient should be upon the bed where he is to lie until cica- 
trization is accomplished, in order after the operation to avoid unne- 
cessary motion and hemorrhage, which would interfere with speedy 
union ; and if he is incapable of self-control, he should be etherized. 
The requisite instruments are a pair of long-bladed forceps, a sharp- 
pointed bistoury, blunt-pointed scissors, and sutures of iron or sil- 
ver wire, or serres-fines. 

Allow the penis to hang without traction in its natural condition, 
and with a pen and ink trace a line upon the skin corresponding to 
the corona glandis, to serve as a guide for the incision. Next draw 
the prepuce forwards, until this line is in front of the glans, and 



108 



PHYMOS1S. 



grasp it between the long blades of the forceps (somewhat more 
obliquely than is represented in the adjoining cut, so as to include 
a larger portion of the prepuce above than below), which should 
be intrusted to an assistant ; the external part is now to be excised 
in front of, and close to the blades of the forceps, having first been 
put upon the stretch by the left hand of the operator. Any at- 
tempt to cut from either margin of the fold will be attended with 

Fig. 1. 




(After Phillips.) 



some difficulty, since the several layers of the skin and mucous 
membrane oppose an amount of resistance to the knife that is not 
readily overcome ; hence, it is better to transfix the centre of the 
flap (the blade of the knife parallel to, in front of, and in contact 
with the forceps), cut downwards, and complete the section by turn- 
ing the knife, and cutting upwards. 

The assistant should now remove the forceps, when the integu- 
ment will retract, carrying its cut edge back to the base of the glans, 
and exposing the raw external surface of the mucous membrane 
which still covers the glans. If the mucous membrane be in a 
healthy condition, it may be divided with scissors along the dor- 
sum, and turned back to be united to the integument ; but if thick- 



CIRCUMCISION. 109 

ened by chronic inflammation, vegetations, or the cicatrix of a 
chancre, more or less of it should be excised. The parts should 
not be brought into coaptation until the bleeding has been arrested 
by exposure to the air, and torsion of the small vessels. Union 
may be effected by means of sutures of iron wire, or serres-fines, 
which should be removed as soon as the edges of the wound are 
securely glued together with lymph, or within twenty-four or forty- 
eight hours. I prefer simple exposure to the air, and protection by 
means of a cradle from contact with the bedclothes, to the water- 
dressing commonly employed, unless union by first intention fails 
to take place, and suppuration ensues. The patient should remain 
in bed until the parts have entirely healed, and, if the contact of 
the urine with the wound cannot be otherwise prevented, should 
micturate with his penis immersed in a basin of tepid water. In 
favorable cases, confinement to the house for two or three days is 
sufficient. 

It would hardly seem necessary to caution the surgeon not to 
excise too large a portion of the integument, were it not for the 
following case reported by Nelaton i 1 A patient appeared at the cli- 
nique who had been operated upon for phymosis eleven days before 
by the usual method. The physician, forgetting that the integu- 
ment of the penis is very lax and extensible, had, before making 
the incision, drawn it forwards to its utmost limits; the consequence 
was that, after the operation, the penis was denuded nearly to the 
abdominal wall. An extensive suppurating surface had remained, 
which was torn and made to bleed by frequent erections. The case 
does not appear to have been followed to its termination, but Nela- 
ton remarks upon the rigidity and malformation of the organ, pro- 
vided cicatrization should take place, and adds that "this case 
shows the importance of marking the limits of the incision before 
the operation." 

The American editor of Erichsen's Surgery states that the favorite 
operation for phymosis at the Pennsylvania Hospital, Philadelphia, 
consists in simple division of the mucous layer of the prepuce, by 
means of fine scissors, one blade of which is sharp, and the other 
probe-pointed. The former is made to penetrate between the two 
layers of the prepuce along the dorsum of the organ, while the 
latter passes between the glans and its envelope, and thus the inter- 

1 Patliologie Cliirurgicale, t. v. p. 663. 



110 PHYMOSIS. 

nal layer may be divided as far as the corona glandis. The pre- 
puce should be retracted several times each day, especially during 
micturition, both in order to prevent contact of the urine with the 
wound, and also immediate union, which would thwart the purpose 
of the operation. 

Faure accomplishes the division of the mucous layer in a simpler 
manner, as follows : The skin of the penis is forcibly drawn towards 
the abdomen, when an incision is to be made with blunt-pointed 
scissors upon the dorsum of the retracted preputial orifice, impli- 
cating the mucous membrane, but sparing the integument. This 
allows of a still farther retraction of the prepuce, bringing into 
view an additional portion of mucous membrane, which, by a suc- 
cession of the above procedures, may be divided to the base of the 
glans. 

These methods, unattended by any loss of substance, may suffice 
when it is desired simply to relieve uncomplicated phymosis ; but 
when the mucous membrane is in a diseased condition, as is 
generally the case when an operation is required, circumcision 
should be preferred. 



PARAPHIMOSIS. Ill 



CHAPTER V. 

PAR APH YM OSIS. 

In paraphimosis the extremity of the penis is strangulated by a 
narrow preputial orifice retracted behind the prominent corona 
glandis, which forms the chief obstacle to reduction. After the 
lapse of a few hours or days, the parts behind and especially in 
front of the stricture become swollen from infiltration of serum and 
fibrine ; the constricting ring is concealed in a deep furrow between 
them, and is still farther retained in its abnormal position by 
adhesion to the deeper textures — the result of inflammatory action. 
Ulceration or gangrene may finally supervene, and perhaps relieve 
the stricture, but with an unnecessary loss of tissue. 

Paraphymosis is frequently met with in boys, as the result of 
their first attempt to expose the glans. It may also follow the 
injudicious retraction of the prepuce when previously affected with 
phymosis, and while the parts are still in an inflamed condition. 

Treatment.-*— When called to a case of paraphymosis, it may 
not be advisable to attempt reduction until the oedema has first 
been diminished by rest in the horizontal posture, elevation of the 
penis, and a saline cathartic, assisted in some cases by scarification 
of the swollen tissues in front of the stricture, the application of ice 
or a stream of cold water directed upon the part. 

Eeduction may often be facilitated by placing the patient under 
the influence of an anaesthetic. The difficulty is frequently increased 
by the vicious manner in which the attempt is made. The swollen 
glans and mucous layer of the prepuce are to be passed through a 
narrow preputial orifice. Mere pressure from before backwards 
will increase their transverse diameter and augment the difficulty 
of reduction ; this can be best accomplished by compressing, and, 
if necessary, elongating them, and drawing the constricting ring 
and integumental layer over them. 



112 



PARAPHYMOSIS. 



Fig. 2. 



To effect this purpose, let the parts in front of the stricture be 
well oiled, and the glans enveloped in a thin rag, that it may afford 
a firmer hold to the fingers. The surgeon steadily compresses the 
glans for ten or fifteen minutes in its transverse diameter, with the 
thumb and fingers of his right hand, and endeavors to relieve its 
distended vessels of a portion of their contents. He then encircles 
the body of the penis with the thumb and fingers of his left hand, 

and draws the integument forwards, 
attempting at the same time to insert 
the right thumb nail beneath the 
stricture, and elevate it above the 
corona glandis, which is most pro- 
minent upon its superior aspect. 

Steady perseverance in the above 
method will rarely fail of success, 
when reduction is possible ; but the 
following modes, recommended by 
different authors, are perhaps worthy 
of description. 

In an ingenious method proposed 
by M. Garcia Teresa, the centre of a 
piece of tape is placed upon the dor- 
sum of the corona glandis, the oppo- 
site ends passed round the sides of 
the glans, crossed beneath the frenum, and wound around the little 
finger of each hand ; the glans is then compressed by flexing the 
middle and ring fingers, and exercising traction in opposite direc- 
tions, while the other fingers remain free to draw the prepuce for- 
wards, and accomplish its reduction. 1 

Dr. Yan Dommelen effects compression of the glans by winding 
around it a strip of adhesive plaster half a yard long, and about a 
quarter of an inch wide, commencing at its base, and terminating 
near the orifice of the urethra. 2 

M. Seutin, of Brussels, has invented a pair of forceps with spoon- 
shaped extremities, to maintain compression of the glans until the 
constricting ring can be drawn over them. 

The three preceding methods are designed for the purpose of 




(After Phillips.) 



» Rev. de Ther. Med.-Chir., Feb. 15, 1860. 
2 Med. Times and Gaz.. Jane 4, 1859. 



TREATMENT. 113 

compressing the glans during reduction ; in the following, which is 
said to be employed with great success at the Children's Hospital, 
in Pesth, compression of nearly the whole organ precedes the 
attempt to restore the preputial orifice to its normal position : — 

The penis is first well cleansed and dried, when a strip of adhe- 
sive plaster, about three lines broad, is applied longitudinally from 
the middle of its under surface, over the swollen prepuce and glans, 
avoiding the meatus, to the middle of the upper surface. Another 
strip is carried in a similar manner from side to side over the glans, 
and in large boys a third, and even a fourth strip, may be required 
to cover the whole organ. Finally, still another strip is firmly ap- 
plied transversely over the preceding, commencing just behind the 
meatus, and continued by successive turns to the middle of the body 
of the penis. The application is said to be well borne, and the 
swelling so diminished within twenty -four hours, that the plaster 
must be renewed ; reduction can usually be effected within forty- 
eight hours. 1 

The late Abraham Colles, Prof, of Surgery at the Eoyal College 
of Surgeons of Ireland, succeeded, after other means had failed, in 
relieving two severe cases of paraphymosis, by passing a director 
beneath the stricture from before backwards, and elevating it upon 
the point of the instrument, while the stem was made to compress 
the swelling in front, and gradually force it back beneath the stric- 
ture. This process was repeated on each side of the penis, after 
which reduction was quite easy. 2 

When reduction is impossible, and ulceration or gangrene threat- 
ens, it becomes necessary to relieve the stricture, by dividing the 
preputial ring, which — as should not be forgotten — is situated at the 
base of the furrow between the swollen folds of mucous membrane 
and integument. This may be done by entering a narrow, sharp- 
pointed bistoury flatwise, and from before backwards, upon the 
dorsum of the penis, turning its edge upwards, and dividing the 
stricture. In some cases, this procedure must be repeated in several 
places, and the swollen prepuce freely scarified, before reduction 
can be effected. 

' Schmidt's Jahrbiicher. 

2 Dublin Quart. Journ. of Med. Sci., May, 1857. 



114: SWELLED TESTICLE. 



CHAPTER VI. 

SWELLED TESTICLE. 

The most frequent complication of gonorrhoea is an affection of 
the scrotal organs, variously known by the names of swelled 
testicle, hernia humoralis, orchitis, and by the more correct term, 
gonorrhoea! epididymitis. In order to understand the mode in which 
this complication supervenes upon gonorrhoea, it is desirable to 
recall to mind the canal which connects the testicle and the urethra, 
and which is designed for the passage of the seminal fluid. Tracing 
this canal from before backwards, we have first the aperture of the 
ejaculatory duct, near the anterior extremity of the veru montanum 
in the prostatic portion of the urethra ; following this duct, we find 
that it merges into the vas deferens, which passes round the bladder, 
through the spermatic canal in the abdominal muscles, and finally 
descends within the scrotum, where it terminates in the numerous 
and intricate convolutions of the epididymis. "We thus have a 
passage, lined with mucous membrane, which is continuous with 
the mucous membrane of the urethra, and connecting the deepest 
portion of this canal with the epididymis. 

In the early stages of urethral gonorrhoea, the inflammation is 
generally confined to the neighborhood of the fossa navicularis. 
At a later period, however, the deeper portions of the canal are 
involved, and the disease thus gains access to the ejaculatory duct, 
and, under the influence of any exciting cause, may extend along 
the spermatic canal to the epididymis, or even beyond this, to the 
testicle and the tissues which envelope it. The patient's own sensa- 
tions will sometimes indicate that in this mode has originated the 
affection of the testicle. He has felt a dull pain in the perineum 
and in the groin, along the course of the spermatic vessels, for a 
day or two before he observed the tenderness and swelling of the 
testis. Again, we may find additional evidence in the fact that the 
cord corresponding to the inflamed testicle can be felt externally 
to be swollen and hard, and can be traced from the testicle through 



CAUSES. 115 

the inguinal canal, even into the iliac fossa. Post-mortem exami- 
nations, also, have exhibited the ordinary appearances of inflamma- 
tory action throughout the whole of the canal connecting the 
testicle and urethra. There can be but little doubt, therefore, that 
in many, and probably in most cases, swelled testicle owes its 
origin to the extension of the inflammation along a continuous 
mucous surface. 

In some cases, however, no evidence of such extension can be 
found either in the sensations of the patient, or in any abnormal 
condition of the cord, which appears to be entirely unaffected. 
These cases are analogous to the inflammation of a lymphatic 
ganglion in the groin or axilla, in consequence of a wound of the 
foot or hand ; the lymphatic vessel connecting the two exhibiting 
no symptoms of inflammation. It may be that the inflammation 
has traversed this vessel, but that its passage has been so rapid as 
not to excite notice, and to leave no traces behind it ; or it may be 
that particles of irritant matter have been conveyed along the duct, 
and lodged in the ganglion. A similar explanation is given in 
cases of swelled testicle without appreciable lesion of the cord, by 
those who refuse to admit any other origin for this disease than the 
direct extension of the inflammatory process. Most authorities, 
however, admit that swelled testicle may be excited through sym- 
pathy alone, without any inflammation, however slight, of the 
spermatic tract, or any passage of irritant matter ; and the subsidence 
of the swelling in one testicle, and its subsequent appearance in the 
other, as is observed in some cases, renders this view probable. 

Causes. — Gonorrhoea of the urethra is the only form of gonor- 
rhoea which gives rise to swelled testicle, which is never met with 
as a complication of balanitis. 

The following table, drawn up by M. de Castelnau, 1 exhibits the 
times of its appearance in the course of the gonorrhoea, in 239 
cases, collected from different sources : — 





Gacssail. 


Despinb. 


AUBKEY. 


De Castelxau. 


Total 


1st week 


. 3 


2 


8 


3 


16 


2d . 


. 4 


6 


17 


7 


34 


3d . 


. 5 


2 


9 


8 


24 


4th " 


. 16 


2 


15 


6 


39 


5th " 


. 39 


2 


8 


5 


54 


6th " and later 


. 6 


15 


43 


8 


72 


Total, 


73 


29 


100 


37 


239 



Annales des Maladies de la Peau et de la Syphilis, May, 1844. 



116 SWELLED TESTICLE. 

In the experience of most surgeons, swelled testicle is even rarer 
during the first fortnight of a gonorrhoea, than would appear from 
the above statistics. As a general rule, it may be said to supervene 
after the third week, and most frequently after the sixth week. 

Cases are reported in which it has occurred after the discharge 
had entirely disappeared, and in one as late as three months. A 
patient once came to me with swelled testicle, five weeks after I 
had treated him for a clap, and had dismissed him as cured, and he 
assured me that he had not perceived any discharge in the mean- 
while, nor could I discover any upon examining the penis. It is 
probable, as stated by Yelpeau, that in these cases there still remains, 
in the prostatic portion of the urethra or at the neck of the bladder, 
a small amount of inflammation, but not sufficient to manifest itself 
externally. 

Instances are recorded in which the swelling of the testicle is said 
to have appeared before the discharge from the urethra. In one 
case reported by M. Castelnau, the epididymitis was developed a 
week after coitus, and the urethral running was first seen five days 
afterwards. M. Yidal (Ann. de Chir., 1844) gives a similar case, 
and Yelpeau (Bid. de Med., art. Testicule) admits such an occur- 
rence. It is not improbable that a gonorrhoea really existed, but 
was overlooked, in these cases ; still it is possible that the prostatic 
portion of the urethra alone received the irritation from coitus, and 
that the effect produced was insufficient to manifest itself by a dis- 
charge until after the swelling of the testicle had taken place. 

In some instances we are able to trace an attack of swelled tes- 
ticle directly to some exciting cause, which has aggravated the 
urethral disease. Thus the patient may have been imprudent in ex- 
ercising or in exposing himself to cold, or he may have indulged in 
a debauch or in sexual intercourse. Strongly irritant injections, or 
any violence done to the canal by a large bougie, or by forcible 
distension when using a syringe, may also occasion it. One of 
the most severe cases of this disease that I ever met with had 
been induced by the forcible introduction of a large bougie in the 
treatment of a gleet of several years' duration. In other instances, 
however, the exciting cause of epididymitis is not apparent, in- 
dependently of the fact that the inflammatory action has had time 
to involve the prostatic portion of the urethra and gain access to the 
spermatic ducts. It has been supposed by some surgeons, that the 
use of copaiba and cubebs, is occasionally the cause of epididy- 



SEAT. 117 

mitis ; while others have not only denied this, but have even re- 
commended these drugs in the treatment of this affection. I have 
already referred to this subject in speaking of the antiblennorrha- 
gics, and will only say at present that evidence is wanting in favor 
of both these assertions. "We have no reason to believe that 
copaiba and cubebs ever occasion this disease, and still less reason 
to believe that they can be used with benefit in its treatment. 

It should not be forgotten that wearing a well-fitting suspensory 
bandage during an attack of gonorrhoea is the best protection 
against swelled testicle. The patient is thus relieved of the weight 
of the scrotal organs, the flow of blood from the part is facilitated,, 
and the liability to inflammatory action is consequently much 
diminished. 

Seat. — G-onorrhceal epididymitis more frequently attacks the 
left testicle than the right. Of 1,342 cases observed by Prof. Sig- 
mund, of Vienna, the left testicle was affected in two-thirds. 1 The 
greater frequency of this disease on the left side has been attributed 
by some authors to the fact that men usually "dress" on this side, 
and that the left testicle consequently receives less support than the 
right. This explanation, however, is very questionable. The dif- 
ference is doubtless to be found in that cause, as yet not explained 
in a perfectly satisfactory manner, which renders the left testicle 
more prone than the right to take on various forms of morbid action. 
Both testicles rarely become inflamed simultaneously, but not un- 
frequently one is attacked after the other. This usually occurs only 
after the lapse of several weeks, though I have seen the two attacks 
separated by only a few days' interval. Sigmund states that both 
testicles were affected in seven per cent, of his hospital patients, and 
in five per cent, of his private cases. Occasionally, the inflammation, 
after leaving one testicle and attacking the other, will return to the 
first ; to this form of the disease Kicord has given the expressive 
name of see-saw epididymitis. 

The best authorities, with but few exceptions, agree in the state- 
ment that it is the epididymis, of all the scrotal organs, which is 
first and chiefly involved in most cases of this disease. It is here 

1 British and Foreign Medico-Chirurgical Review, Oct. 1856. 

Mr. Curling denies that the left testicle is most frequently affected (Diseases of 
the Testis, p. 226), but his statement is founded on 138 cases only, which are far 
inferior in number to the above statistics of Prof. Sigmund. 



118 SWELLED TESTICLE. 

that the vas deferens terminates, and we may suppose that the in- 
flammatory action is retarded in its progress by the innumerable 
and intricate convolutions which compose this appendage to the tes- 
ticle. At an early stage of the inflammation, and also after the 
swelling has somewhat subsided, the epididymis can be felt en- 
larged to several times its natural size. The normal position of 
the epididymis is posterior and external to the body of the testicle, 
and pressure upon this part excites more pain than elsewhere. The 
epididymis, not being enveloped, like the testicle, in a fibrous cap- 
sule, is susceptible of an indefinite amount of tumefaction, and fre- 
quently enlarges to such an extent as to partially surround and 
encase the body of the testis. 

It should be recollected, however, that the position of the epi- 
didymis, relative to the testicle, may be abnormal ; in which case 
the seat of the greatest tenderness and swelling will differ from the 
description just now given. Such malpositions are called by the 
French inversions du testicule. They have recently been thoroughly 
investigated for the first time by M. Eugene Koyet, 1 who admits the 
five following varieties : — 

1. The epididymis may be anterior to the body of the testicle. 

2. It may be on one side, either the external or internal. 

3. It may be superior ; the long axis of the testis being antero- 
posterior, and the epididymis resting upon its upper surface. 

4. In the fourth variety, the epididymis and vas deferens form a 
loop or sling, which surrounds the testis from before backwards. 

5. In the fifth variety, the relative position of the epididymis and 
testis varies from day to day, without appreciable cause. 

All these varieties are rare, with the exception of the first, which, 
according to Eoyet's researches, is met with in one out of every 
fifteen or twenty persons. The abnormal position of the epididymis 
in front of the testicle is, therefore, the only one possessing much 
practical importance. The possibility of this malposition should be 
borne in mind both in operating for hydrocele and when forming a 
diagnosis of scrotal tumors. In cases of epididymitis, when the in- 
flammation is not general, the epididymis may be recognized by its 
hardness to the touch and its sensibility to pressure. "When all the 
scrotal organs are involved in the inflammatory process, Eoyet 
states that the chief means of recognizing an anterior position of the 

1 De l'lnversion du Testicule ; Paris, 1859, pp. 55. 



SEAT. 119 

epididymis, are a want of mobility in the skin anteriorly, and the 
fact that the vas deferens can be felt in front instead of behind the 
other vessels of the cord. 

Next to the epididymis, the tunica vaginalis is most frequently 
involved in gonorrhoeal epididymitis. M. Eochonx has advanced 
the idea that inflammation of this membrane is the chief and con- 
stant lesion in swelled testicle ; but this is a mistake. Vaginali- 
tis, although a very frequent, is not a constant symptom, and is 
always consecutive to the inflammation of the epididymis. There 
is commonly an effusion varying in quantity and character, within 
the tunica vaginalis. This may consist only of serum and be ap- 
parently due to simple obstruction of the circulation ; or it may 
contain fibrin and other products of inflammation. Sometimes 
bands of lymph bind the two opposed surfaces together, as in pleu- 
risy. The sub-scrotal cellular tissue also participates in the inflam- 
matory action, and is thickened by oedema or fibrinous deposit. 
The frequency with which the tunica vaginalis is involved in 
swelled testicle, while the body of the testicle is unaffected, has 
been explained by Gendrin, 1 who states that when the cellular 
tissue of an organ is continuous with that underlying a neighboring 
serous membrane, it becomes a ready means of communicating in- 
flammatory action ; but when a contiguous organ is not thus con- 
nected with the original seat of the disease, the passage of the 
inflammation is less easy. The connecting link between the epi- 
didymis and tunica vaginalis is found in the areolar tissue which 
penetrates the former and underlies the latter, while the testicle is 
surrounded by the fibrous tunica albuginea, and, being thus isolated, 
generally escapes. 

Following the tunica vaginalis in the order of frequency, the 
spermatic cord is next found to be the seat of inflammatory action in 
gonorrhoeal epididymitis. The body of the testicle is rarely affect- 
ed ; and even when involved, the fibrous tunic which invests it limits 
the amount of swelling of which it is capable, although it greatly 
increases the suffering of the patient by constricting the inflamed 
tissues. 

Some idea of the comparative frequency with which the different 
tissues now mentioned are attacked in this disease may be formed 
from the statistics of Prof. Sigmund, already referred to. In 1342 

1 Histoire Anatomique des Inflammations, t. i. p. 143. 



120 SWELLED TESTICLE. 

cases, the epididymis was alone affected in 61 ; the epididymis and 
tunica vaginalis in 856; the epididymis and cord in 108, and these 
three parts together in 317. 

The propriety of the name, gonorrhoeal epididymitis, will now 
be evident. It is no objection to this term that the epididymis, 
in many cases, is not the only part involved. As in diseases 
of the eye, we call a certain inflammation iritis, though other parts 
besides the iris are involved, so in swelled testicle, the principal 
seat of the disease should determine its scientific name. The term 
orchitis, which is adopted by Yidal, Velpeau, and most English 
authors, is less correct, and is moreover objectionable, because it is 
calculated to confound this disease with that affection of the testicle 
which is produced by constitutional infection, and which is totally 
distinct in its character and symptoms. 

Symptoms. — There are generally no marked premonitory symp- 
toms preceding an attack of swelled testicle. Sometimes, however, 
we find that the patient has suffered from malaise for several days ; 
that he has had slight fever, perhaps a chill, and a dull pain or heavy 
sensation in the perineum, cord, and scrotal organs, attended with a 
frequent desire to pass water. His attention is soon attracted to the 
testicle by pain, felt especially on motion, and on examination he 
finds this organ swollen, and tender on pressure. The swelling and 
tenderness rapidly increase, and the pain extends to the correspond- 
ing thigh, to the groin, and to the lumbar region. In the course of 
twenty-four or forty-eight hours, the affected side of the scrotum 
may have attained the size of the fist; the skin is tense and in 
some cases of a dark red or almost purplish hue ; the pain is very 
severe, especially at night, preventing sleep ; the least pressure upon 
the part, even from the bedclothes, is almost unendurable; partial 
ease only can be attained by keeping perfectly quiet in the horizon- 
tal posture with the addition of some support to the genital organs. 
If the cord be involved, the pain, swelling, and tenderness are found 
to extend upwards to the inguinal canal. There is generally more 
or less febrile disturbance of the system at large. The skin is hot, 
the tongue coated, the pulse increased in force and frequency, and 
the patient extremely nervous and agitated. Cases are reported in 
which the swelling of the cord was so excessive as to produce stran- 
gulation at the abdominal ring, attended by symptoms resembling 
those of strangulated hernia, such as abdominal tenderness and 



SYMPTOMS. 121 

vomiting. It must not be supposed, however, that the symptoms 
are always so severe as those now described. Such severity is more 
apt to be met with in persons of a nervous temperament, in whom 
this disease is one of the most distressing that can occur. In other 
cases, however, the suffering is comparatively slight, and I have 
known patients to attend to their daily occupation during its whole 
course. Between these two extremes we may have every shade of 
variation. 

While the inflammation is at its height it is impossible to distin- 
guish the different portions of the scrotal organs. Judging from 
mere inspection of the swelling, we might be led to suppose that it 
was chiefly made up of the body of the testicle. This, however, is 
not so. It is composed, for the most part, of the swollen epididy- 
mis, of an effusion into the tunica vaginalis, and of oedema of the 
subscrotal cellular tissue. The hydrocele is often, but not always, 
sufficient to enable us to detect distinct fluctuation, and rarely, if 
ever, is the tumor transparent ; but on gently touching it, the surface 
is found to yield for a short distance before the fingers come in con- 
tact with the firmer body of the testicle beneath. This yielding is 
due to the displacement of the oedema of the scrotum and of the 
fluid in the sac. If the tumor be punctured with a lancet, bloody 
serum, varying in amount from a few drops to several drachms, will 
escape. 

Kesolution begins to take place in a few days, commencing in the 
anterior portion of the tumor. The oedema of the scrotum and the 
hydrocele disappear, and the different portions of the testis can now 
be distinguished from each other — the epididymis, still swollen and 
hard, behind; and the body of the testicle, preserving, in most 
cases, its normal elasticity, in front. The whole duration of the 
attack varies from one to three weeks. In a discussion on the treat- 
ment of this disease before the Academy of Medicine in Paris, in 
1854, Yelpeau stated that its duration under ordinary methods of 
treatment averaged 16 or 18 days. 

In some cases of swelled testicle, after the more acute symptoms 
have subsided, the parts still remain engorged and the disease shows 
a tendency to become chronic. This is most likely to occur in 
patients of weak habit, and while this condition lasts the least ex- 
citing cause may induce a return of the acute inflammation. 

Most cases of swelled testicle terminate favorably. In some rare 
instances, however, abscesses form in the cellular tissue underlying 



122 SWELLED TESTICLE. 

the scrotum, or in the epididymis or body of the testicle. Mr. 
Edwards 1 has recently reported a case in which the whole testicle 
protruded through an opening formed by an abscess in the scrotum, 
the skin being drawn in around the orifice. Mr. Edwards " pared 
the edges, drew them asunder, making with the handle of the scalpel 
a sufficient separation of the deeper tissues, and the testicle was at 
once drawn, as it were, back into the scrotum, the wound closing 
over it. Three hare-lip pins were inserted ; the wound closed by 
first intention, and the patient was walking about perfectly well 
on the seventh day." If suppuration takes place in the testicle, 
the pus generally burrows in various directions, forming sinuses, 
and destroying a portion of the parenchyma; sometimes a cir- 
cumscribed abscess is formed, which may become encysted, and, 
the more fluid portion being absorbed, the solid portion may re- 
main in a concrete state for an indefinite length of time, and closely 
resemble a tubercular deposit. The presence of the cyst will clear 
up the diagnosis, since true tubercular matter is always found in 
direct contact with the parenchyma of the testis, and is never met 
with encysted. 

The swelling of the testicle attendant upon gonorrhoea may, 
however, be the exciting cause of true tubercular deposit, in per- 
sons of a strumous diathesis. 2 

As the epididymis was the first part attacked, so it is the last to 
recover its normal condition, and in some cases it retains, for months 
or years, an irregular and knotty mass of induration, which may 
obstruct the passage of the semen and render the affected testis 
useless. If this induration exist on both sides, or if the opposite tes- 
ticle be undeveloped, as is often the case with an undescended testis, 
the patient will probably be impotent. In a few rare cases gonor- 
rhceal epididymitis has been known to terminate in atrophy of the 
testicle. 

The condition of the urethral discharge preceding and during an 
attack of swelled testicle has been the subject of considerable dis- 
cussion. It was at one time supposed that this complication of 
gonorrhoea was usually preceded by a diminution of the running, 
and hence that it might be attributed to the use of active measures 
which were supposed to drive the disease from the urethra to the 

> Edinb. Med. Journal, Nov. 1860, p. 455. 

2 A case of this kind was recently exhibited at a meeting of the Anatomical 
Society of Paris. Bulletin de la Soc. Anat. de Paris, 2d serie, t. iv. p. 2. 



SYMPTOMS. 



123 



Fig. 3. 



testicle. On this supposition has been founded the theory that 
swelled testicle may be caused by metastasis. A proper apprecia- 
tion of the facts in the case, however, does not warrant this' conclu- 
sion. It is, indeed, true as a general rule, that the urethritis has 
passed the acute stage and that the discharge has consequently 
diminished before the epididymis becomes inflamed, 1 but, this is 
the natural course of the disease when no complication whatever 
takes place. To prove a metastatic origin of the epididymitis, it 
would be necessary to show that there is a sudden disappearance 
or diminution of the running, just preceding the swelling of the 
testicle ; such, however, does not occur. On the contrary, as stated 
by Eicord, there is often an exacerbation of the urethral disease 
and a slight increase of the discharge 
for a day or two preceding. When 
the disease of the testicle is fairly es- 
tablished, the discharge diminishes 
as a consequence of revulsive action. 
These phenomena coincide with what 
is seen in affections of other parts 
when acute inflammation is estab- 
lished in their neighborhood. 

The induration of the epididymis, 
which frequently remains for some 
time after an attack of swelled testi- 
cle, or which may even become per- 
manent, requires farther mention. 
This induration is commonly situated 
in the lower part of the epididymis, in 
or near the globus minor. It will be 
recollected that the upper portion, or 
globus major, is composed of the con- 
volutions of the vasa efferentia, which 

o , . . n Vertical section of the testis and epididy 

are from ten to thirty m number, but mis . (A f ter gray.) 




1 Gaussail's statistics relative to the discharge are as follows : In 67 of 73 cases 
the discharge and the other symptoms of the gonorrhoea had diminished more or 
less— in other words, the acute stage of clap had passed— when the swelling of the 
testicle took place ; in 6 cases, the gonorrhoea was still at its height. 

In 30 of the 73 cases, the discharge gradually diminished and disappeared entirely 
during the treatment of the epididymitis ; in 43 cases, some discharge remained 
after the disease of the testicle was cured. 



124: SWELLED TESTICLE. 

that these minute vessels unite into a single duct, before leaving this 
portion. Hence the globus major of the epididymis consists of several 
seminiferous tubes, any one of which would be sufficient to convey 
the semen, in case the others were obstructed ; while the body and 
globus minor contain but one tube, the obliteration of which must 
completely cut off the communication between the testis and the 
penis. But it is in this latter portion, viz., the globus minor, that 
the induration left by an attack of swelled testicle is almost invari- 
ably found ; and, as we shall presently see, it generally effects the 
obliteration of the single duct of the part, and renders the patient 
impotent upon the affected side. 

It now becomes an interesting subject of inquiry, what effect this 
obliteration has upon the testis, whether it becomes atrophied, or 
whether it remains in a normal condition, and continues to secrete 
sperm. Again, in those cases in which epididymitis has occurred 
on both sides, an induration may be left in each testicle, totally ob- 
structing the passage of semen ; in such cases does the patient still 
retain sexual desires ; is he capable of sexual intercourse ; and if 
so, how does his semen differ from that of a perfectly healthy indi- 
vidual ? These questions have been ably answered in a paper by 
Dr. L. Grosselin, published in the Archives Generales de Medecine, for 
Sept. 1853. 

Dr. Grosselin's conclusions are based upon experiments upon the 
lower animals, and upon the observation of nineteen patients af- 
fected with double induration of the epididymis following gonor- 
rhoea. The spermatic cord of one side was exposed in two dogs, 
the vas deferens isolated from the spermatic vessels, and a portion 
of it excised. The animals were killed several months after, when 
it was found that the testicle of the side operated on presented the 
same volume, color, and general character as that of the opposite 
side ; the only difference was that the convolutions of the epididy- 
mis in the former were distended with fluid, containing a mul- 
titude of spermatozoa. The excision of a portion of the vas 
deferens had completely cut off the communication with the penis. 
These experiments proved that isolation of the testicle in the lower 
animals does not produce atrophy of this organ, which remains in 
an apparently healthy condition, and continues to secrete semen. 

The nineteen persons who had had double epididymitis were met 
with at the Hopital du Midi, and in the private practice of Dr. Gos- 
selin. The time which had elapsed since the formation of the indu- 



SYMPTOMS. 125 

ration, at the time of the observation, varied from a few weeks to 
ten years. The symptoms which they presented were in some re- 
spects singular and remarkable. In all of them there was a mass 
of induration in the lower portion of the epididymis of each testicle. 
In none of them was there any apparent change in the volume of 
the scrotal organs, and no pain was felt at any time, not even after 
sexual intercourse. Kone of them had observed any change in 
their sexual desires or powers. They were all as capable of coitus 
as the most healthy individuals. Their erections and ejaculations 
were complete. Their semen was normal in quantity, in consist- 
ency, in odor, and color ; it presented the chemical reactions de- 
scribed by Berzelius, as characteristic of sperm. Only when 
examined by the microscope, was it found to differ at all from 
healthy semen, inasmuch as it was entirely destitute of spermatozoa. 
In the recent cases, most of which were still affected with urethritis, 
pus and blood-globules were found mixed with the semen ; in the 
older cases, these were absent. The entire absence of spermatozoa 
in all of them was confirmed by repeated examinations by Drs. 
Gosselin, Eobin, Yerneuil, and other eminent Parisian microscopists. 
In two of these cases, treatment, continued in the one case for three 
months, and in the other for nine, resulted in the disappearance of 
the induration in one of the testicles, and coincidently with this 
resolution spermatozoa again appeared in the semen, as shown by 
microscopical examination. 

These cases are of the highest interest, looking at them both in 
the light of physiology, and of pathology and therapeutics. They 
show, in the first place, that the quantity of fluid ejaculated is as 
abundant and presents the same general appearances when the canal 
of the vas deferens is obliterated as when it is free ; also, that in 
case of obliteration, the secretion of sperm in the testis is not 
sufficient to distend the vessels to any great extent, or to occasion 
pain. Probably there is some absorption of the secreted sperm, 
but if as much of this fluid were secreted by the testicles as is 
commonly supposed, the effect upon the testicular vessels and upon 
the feelings of the patient would be more manifest. From these 
facts Dr. Gosselin concludes, that the normal function of the tes- 
ticle is to furnish the fecundating element of the sperm, viz., the 
spermatozoa ; and that the other components of the spermatic fluid, 
to which it owes its color, odor, and chemical reactions, and which 



126 SWELLED TESTICLE. 

constitute the medium in which the spermatozoa live, are derived 
for the most part from the vesiculaB seminales. 

But the conclusions from these facts which chiefly interest us at 
the present time, are those bearing on the pathology and treatment 
of epididymitis. These conclusions, as stated by Dr. Gosselin, are 
the following : — 

1. The induration is generally situated in the globus minor of 
the epididymis, though it may, strictly speaking, be seated in any 
part of this organ. Since the epididymis below the globus major 
is composed of but a single vessel, the obliteration of this vessel is 
sufficient to prevent the passage of the sperm. 

2. The presence of the induration excites no pain, provided that 
the inflammation which produced it has entirely subsided. 

3. It does not occasion any change, appreciable by the patient, 
in the exercise of the genital functions. 

4. If the spermatic vessel be obliterated on both sides, the patient 
is necessarily impotent; if on one only, fecundation is possible, 
provided that the other testicle is sound. 

5. The success of treatment in several of the cases reported 
affords assurance that the power of fecundation may sometimes be 
restored by appropriate remedies. 

M. Godard states that he has confirmed Gosselin's observations 
by microscopical examination of the semen of more than thirty 
persons affected with double chronic epididymitis ; and in every 
instance spermatozoa were wanting. 1 

If gonorrhceal epididymitis attack a testicle which has been 
arrested in its descent from the abdomen to the scrotum, the nature 
of the case may readily be mistaken. If the testis have not left the 
abdominal cavity, it may simulate peritonitis or iliac abscess ; if it 
be arrested in the spermatic canal, it may counterfeit strangulated 
hernia or bubo ; and the liability to error is especially great, when, 
as often occurs, the tunica vaginalis is still connected with the 
abdominal cavity, and true peritonitis is set up by extension of the 
inflammation, attended by its usual alarming symptoms. Numerous 
cases in illustration of these remarks may be found in the work of 
M. Godard before referred to. 

A still rarer abnormal position of the testicle is in the perineum ; 

1 Etudes sur la Monorchidie et la Cryptorchidie chez l'Homme ; extrait des Me- 
moires de la Soc. de Biologie, annee 1856, Paris, 1857, p. 105. 



SYMPTOMS. 127 

an anomaly first observed by John Hunter, who met with two 
cases. " Many years ago, a little boy, one of whose testicles had 
thus deviated from its proper course, was brought to the London 
Hospital. The gland was lodged in the perineum at the root of 
the scrotum." 1 Eicord and Yidal 2 (de Cassis) have each observed 
two cases; Mr.Ledwich 3 met with one in a dissecting-room subject, 
and Godard 4 gives the history of another, with a plate of the abnor- 
mity. These nine cases are all with which I am acquainted. A 
perineal testicle affected with gonorrhoea!, epididymitis may simulate 
a perineal abscess or inflammation of Cowper's glands, as in the 
two instances observed by Eicord. 5 " In one, there was a perineal 
tumor, which was exquisitely painful, fluctuating and about the 
size of a pigeon's egg. It was at first taken for an abscess, and 
Eicord was about to open it, when examination of the scrotum led 
to the discovery that one testicle was absent." 

There is another consideration connected with abnormal position 
of the testicle, which is worthy of mention. In most cases of this 
anomaly, the gland is useless for the purposes of procreation. 
According to Goubaux and Follin, 6 it undergoes fibrous or fatty 
degeneration. This is denied by Godard, who, however, has equally 
shown that the gland, as a general rule, is impotent, by microscopical 
examination of the contained sperm after death. In eight cases out 
of nine, spermatozoa were wanting. Now, if the anomaly be con- 
fined to one side, and the opposite testicle be in a healthy condition, 
fecundation is still possible ; but if the descended testicle be attacked 
by epididymitis, obliteration of its vas deferens will deprive the 
patient of all procreative power, as in the cases of double epididy- 
mitis observed by Gosselin. Godard gives the history of a man 
with one undescended testis, who had a child by a mistress, but 
who, after an attack of swelled testicle on the opposite side, was 
twice married without progeny, and his semen, twenty-one years 
afterwards, was found destitute of spermatozoa. 

1 Curlixg, op. cit., p. 46. 

2 Traite de Pathologie Externe, t. 5, p. 432. 

3 Dublin Quart. Journ. of Med. Sci., Feb., 1855. . 

4 Op. cit., page 65, and Plate III. 

6 GrODAKD, Op. Cit., p. 96. 

6 Follin, Etudes Anatomiques et Pathologiques sur les Anomalies de Position et 
les Atropines du Testicule ; Arch, de Med., Juillet, 1851, p. 262. 

G-oubaux et Follin, De la Cryptorchidie chez l'Homme et les Principaux Animaux 
Domestiques ; Mem. de la Soc. de Biolog., 1855, p. 317. 



128 SWELLED TESTICLE. 

Pathological Anatomy. — Since epididymitis, when -uncom- 
plicated, is never fatal, opportunities for post-mortem examination 
are rare, and only occur in case some intercurrent disease produce 
the death of the patient. The most complete report of such 
examination with which I am acquainted, is to be found in the 
Gazette des Hopitaux, for Dec. 21, 1854. 

Case. The patient entered Yelpeau's wards at la Charite with swelled 
testicle, of eight days' duration ; the epididymis was situated in front of 
the testicle, and was swollen and hard ; the cord was also involved, while 
the body of the testicle appeared to be sound, and there was no effusion 
in the tunica vaginalis. 

Eighteen days after his admission, and twenty-six after the commence- 
ment of his attack, this patient died of cholera. The post-mortem was 
made by M. Gosselin, with the following result : — 

1. The tunica vaginalis contained no fluid and was free from injection 
of its vessels. 

2. The body of the testicle was healthy. 

3. The globus major and the body of the epididymis were also healthy; 
but the globus minor was swollen and formed a hard, uniform mass, the 
size of a haricot bean. On cutting open this mass, it was found to be 
destitute of bloodvessels, of a uniform yellow color, resembling tubercle, 
and of firm consistency. The sections of the convoluted spermatic duct 
upon the cut surface showed that this vessel had attained three or four 
times its natural size, and, instead of being hollow, that it was filled with 
uniform yellow matter ; there was none of this matter between the convoluted 
vessels: it was entirely within, and in the substance of the walls. M. 
Robin examined this matter under the microscope and found pus-globules, 
mixed with fat-globules and the granular globules of inflammation. He 
also confirmed the statement that this matter was limited to the interior 
of the vessels. 

4. The vas deferens, which had recovered its normal size, was filled 
with yellowish matter, containing no spermatozoa and composed of pus- 
globules, cylindrical epithelial cells, and granular corpuscles. Its walls 
exhibited a perfectly normal appearance. 

5. The vesicula seminalis on the affected side was healthy. It con- 
tained a small amount of fluid, with pus-globules and epithelial cells, but 
no spermatozoa. Spermatozoa were found in the vesicula seminalis on 
the opposite side. 

M. Gaussail {Arch. Gen. de Med., 1831, torn, xxvii. p. 188) has 
also reported two cases of post-mortem examination of swelled 
testicle, in which, however, the examination was made with less 
care than in the case just quoted. 



PATHOLOGICAL ANATOMY. 129 

Case. In the first case, the patient died of acute arachnitis after suf- 
fering from swelling of the right testicle for ten days, and of the left 
for five days. The vesiculae seminales were found enlarged and indu- 
rated, and their internal surfaces, especially the portion contiguous to the 
ejaculatory ducts, much injected. The cavity of each was filled with 
matter of a yellowish white color and slightly granulated. The vasa 
efferentia were thickened throughout, their cavities contracted and filled 
with matter similar to that in the vesiculae, and their internal surfaces 
injected. 

The epididymis on each side was enlarged and hard ; its external sur- 
face of a reddish hue, which did not extend to the surface of the testicle. 
They both contained matter analogous to that found in the vesiculae. 
The testicles preserved their normal size and exhibited no lesion except 
marked injection of the small vessels entering into the substance of the 
left testicle. There was a small amount of reddish serosity in the tunica 
vaginalis. Traces of inflammatory action were found in the bulbous and 
prostatic portions of the urethra. 

Case. In the second case, the patient died of typhoid fever thirteen 
days after the commencement of an attack of swelled testicle on the right 
side. 

The vesiculae seminales were distended with a large quantity of sper- 
matic fluid, which was thicker than natural, but did not present the yellow 
color noticed in the preceding case. The left vas deferens (on the opposite 
side to the affected testicle) was engorged from the urethra to the poste- 
rior opening of the inguinal canal ; the right was thickened throughout, 
while its cavity was diminished ; its internal surface was red and the in- 
jected vessels very apparent. The right epididymis was double its usual 
size and very hard. On first examination the testicle appeared to be 
much larger than normal ; but on opening the tunica vaginalis, a quantity 
of thick, muddy, and slightly bloody fluid flowed out, leaving the testicle 
nearly of its natural size. The tunica albuginea appeared to be thickened 
and a network of numerous small vessels was spread over its outer sur- 
face. The substance of the body of the testicle was not perceptibly 
changed, except that it was a little more consistent and of a deeper color 
than natural. 

Mr. Curling (op. cit., p. 209) says that lie has twice had the 
opportunity of making a post-mortem examination of swelled 
testicle, but gives no account of the appearances presented. Mr. 
Brodie 1 examined the body of a gentleman who had had gonor- 

1 Clinical Lecture on Diseases of the Testis ; London Medical Gazette, vol. xiii. p. 
219, 1834. 
9 



130 SWELLED TESTICLE. 

rhoeal epididymitis twenty years before, and found the testicle 
smaller than natural and " one-third of the tubuli testis converted 
into a white substance, having the consistence, but not the fibrous 
structure, of ligament." 

The first case which I have quoted as occurring in the service 
of M. Yelpeau, is, I believe, the only one on record, in which the 
examination has been made with all the light which modern science 
affords, and I would especially call attention to the fact that the 
fibrinous deposit was found to be situated within the vessel of the 
epididymis and not between the convolutions. This fact is in 
opposition to the statement of Mr. Curling ; but it can hardly be 
called in question in the case here reported, and it strongly favors 
the opinion of M. Gosselin that the communication between the 
testis and the penis is almost invariably obstructed during an acute 
attack of epididymitis, and also during the continuance of the in- 
duration which is often left behind. I would not be understood 
as asserting, however, that the exudation is always confined to the 
interior of the vessel ; it may also involve the areolar tissue con- 
necting the convolutions, but its deposit in the former situation 
appears to be the more persistent, and the more important so far as 
the procreative powers of the patient are concerned. 

The pathological changes produced by epididymitis can only be 
studied to advantage in recent cases. In the masses of induration 
which have existed for months or years, the anatomical elements 
are so confounded that it is impossible to distinguish them. 

Teeatment. — The treatment of gonorrhoeal epididymitis should 
be decidedly antiphlogistic. It is indeed true that under temporizing 
measures, the inflammation will subside in time, but an effusion of 
plastic lymph, endangering the procreative powers of the patient, 
will be more likely to occur, than when the case is treated actively 
at the outset. 

Eest in the horizontal posture, even if the feelings of the patient 
do not demand it, should be strictly insisted on. As the patient 
lies in bed upon his back, the scrotal organs should be supported 
by a number of folded towels, placed between the thighs, or by a 
folded handkerchief arranged around them like a sling, with its 
ends attached to a bandage round the waist. I usually order an 
emetico- cathartic, as in the following prescription : — 



TREATMENT. 131 

R,. Antimonii tartarizati gr. iv. 

Magnesias sulphatis t ^iss. 

Aquae camphorae §vj. 
M. 

I direct the patient to take a tablespoonful of this mixture every 
twenty minutes or half hour, until free vomiting has been excited, and 
then repeat the same quantity every few hours, or sufficiently often 
to keep him slightly nauseated and to produce a number of evacua- 
tions from the bowels during the day. If the case be at all severe, 
the application of leeches should not be omitted. It is better to 
apply them over the cord, directly below the external abdominal 
ring, rather than upon the scrotum. They thus deplete the part 
even more directly than in the latter situation, and any irritation 
from their bites is avoided. Their number should vary from four 
to ten, according to the severity of the case. They rarely fail to 
reduce the swelling and greatly relieve the pain ; in some cases, 
however, they require to be repeated in twenty-four or forty-eight 
hours, or after the lapse of a few days, in case the symptoms, after 
once subsiding, again become aggravated. In the absence of leeches, 
blood may be drawn from several of the scrotal veins. The patient 
should stand up, and the parts be bathed with hot water until the 
veins are well distended, when they may be opened with a lancet. 
When a sufficient quantity of blood has been drawn, the patient 
should again lie down and the flow of blood will usually cease in a 
short time ; or, if excessive, it may be arrested by compression with 
serves fines, ordinary forceps, or by one of the haemostatics. 

Both cold and hot local applications have been recommended in 
this disease. Judging from my own experience, the former, when 
applied at the outset, will often succeed in arresting the progress of 
the inflammation ; but when the disease is fairly established, the 
latter are more grateful to the patient and more effectual in hasten- 
ing resolution. If called sufficiently early, I usually order half an 
ounce of muriate of ammonia to be dissolved in a pint of water, and 
direct the patient to keep a single thickness of cloth wet with this 
lotion applied to the scrotum. Simple cold water may be used in 
place of the solution of muriate of ammonia, although I consider 
the latter preferable. The bedclothes should be kept elevated, so 
that evaporation may be free and the temperature of the part re- 
duced. In the course of a few hours, ice may gradually be added 
to the solution, with comfort and benefit to the patient, and his 



132 SWELLED TESTICLE. 

sensations may be taken as an index of the degree of cold required. 
At night, the frequent wetting of the cloths would prevent rest, and 
it is better, therefore, to remove them. Extract of belladonna, 
moistened with a little water, and smeared over the scrotum, may 
now take the place of the lotion, and will ease the pain and favor 
sleep. The internal administration of an opiate may also be re- 
quired. 

If cold applications are not well supported, or if, in spite of our 
efforts, the pain and swelling increase, poultices of bread and hot 
water, or linseed meal, should be substituted for the cold lotion; or 
in robust subjects, poultices of tobacco leaves may be employed for 
the purpose of obtaining the nauseating and sedative effect of this 
narcotic. 

If at any time in the course of the treatment we have reason to 
suppose there is a collection of fluid in the tunica vaginalis, it is 
best to evacuate it. Yelpeau directs, in performing this operation, 
that the tumor should be rendered tense by grasping it posteriorly 
as in the operation for hydrocele, and that the lancet, plunged into 
the cavity of the tunica vaginalis, should be retained in the wound, 
and gently twisted on its axis, in order to preserve the parallelism of 
the incisions in the skin and mucous membranes, until all the fluid 
escapes. I have not found this latter precaution necessary. When 
a broad lancet is used the wound is sufficiently patent, and the 
parallelism of the incisions is preserved by retaining the hold on 
the scrotum posteriorly ; indeed the fluid escapes more freely with 
the instrument withdrawn. 

I have found the results of the above method of treatment very 
satisfactory. Kesolution generally commences within 24 or 36 
hours, and the patient is rarely confined to his room longer than 
five days, or a week. 

When the swelling has been somewhat reduced and the pain dis- 
sipated, and the parts will bear gentle handling, resolution may be 
hastened by the application of strips of adhesive plaster so as to ex- 
ercise compression upon the testis. This method of treatment was 
first suggested by Dr. Fricke, of Hamburg, and is known by his 
name. 1 It is not to be used until the acute symptoms have sub- 
sided, nor while the spermatic cord is much engorged, nor if there 

1 Dr. Fricke's paper was published in the Zeitschrift fur die gesammte Medicin. 
B. j. h. 1. Hamburg, 1836. A translation of it appeared in the British and Foreign 
Medical Review, vol. ii. 1836, p. 253. 



TREATMENT. 133 

is reason to fear the formation of an abscess in the testicle or sub- 
scrotal cellular tissue. The objections which have been urged 
against this method have been founded upon its indiscriminate use. 
The feelings of the patient after the straps are applied will indicate 
whether they should be continued or not. If applied at the proper 
stage of the disease, they will afford a sensation of support and 
relief; should they increase the pain, they are doing harm and 
ought to be at once removed. 

A mixture of two parts of adhesive plaster with one part of 
extract of belladonna spread upon' thin leather, is more elegant, 
and, in many respects, better than adhesive plaster alone. It is 
softer, more elastic, less likely to chafe the skin about the cord, is 
removed with greater facility and ease to the patient, owing to its 
adhering less firmly to the skin and hairs, and, moreover, the 
belladonna acts powerfully as a sedative. 

Before applying the plaster, the hair should be carefully removed 
from the scrotum with a razor or scissors. The plaster is to be 
cut into strips about three-quarters of an inch in width. The tes- 
ticle is now to be pressed down to the lower portion of the sac and 
held there by the thumb and forefinger of the left hand, while a 
strip is placed firmly round the affected side of the scrotum just 
below the abdominal ring. Successive strips are added, each 
overlapping the preceding for one-third its width, and care being 
taken that they all fit smoothly, until all but the bottom of the 
testicle is enveloped ; the latter should then be covered with strips 
applied longitudinally, like the bottom of a wicker basket, and 
finally, the whole is to be secured by a long narrow strip carried 
circularly several times around the whole. In the course of from 
twelve to twenty four hours, the plaster will be found to be loosened 
by the decrease of the swelling, when it should be removed and 
fresh strips applied. The compression should be continued until 
the testis has nearly returned to its normal dimensions, and in the 
meanwhile the parts still be supported by a bandage. 

The application of collodion to the scrotum as a means of com- 
pression, suggested by M. Bonnafont, was a subject of discussion 
before the Academy of Medicine in Paris, in 1854, and a trial was 
made of it by Eicord and others, who reported against it. 

In those cases in which, after the subsidence of the acute symp- 
toms, the testicle remains in a condition of chronic engorgement, it 
is not best to persevere in an antiphlogistic course of treatment. 



134 SWELLED TESTICLE. 

The diet should be nourishing, but not stimulant. Any effusion 
into the tunica vaginalis should be evacuated and the scrotal organs 
carefully strapped. The bowels should be kept free, and marked 
benefit will be derived from small doses of mercurials, as, for in- 
stance, a few grains of blue mass administered every night at bedtime. 
Opinions as to the propriety of treating the urethritis during an 
attack of swelled testicle have been widely different. Those who 
believe in the metastatic origin of epididymitis, have not only 
refused to take measures to cure the urethral discharge while the 
testicle was still inflamed, but have even advised that the urethra 
should be irritated by bougies or otherwise, so as to recall the 
disease to its original seat. Such practice . is founded on a false 
assumption, and is both useless and dangerous. The continuance 
of the urethritis can only aggravate the epididymitis, or tend to 
produce a relapse if it has already subsided. The cure of the ure- 
thral discharge can alone afford security for the future. This, 
however, is not to be attempted by irritant injections. I am in the 
habit of employing the injection of glycerin, extract of opium, and 
sulphate of zinc, which I have recommended in the acute stage of 
gonorrhoea, never, however, adding a sufficient quantity of the 
sulphate to excite more than a momentary prickling sensation in 
the canal. The following formula is generally applicable : — 

fy. Extracti opii 9j. 

Glycerin §j. 

Zinci sulphatis gr. vj-xij. 

Aquae ^vj. 
M. 

The necessity of confining the patient to his bed for a period 
may be regarded as a very fortunate one, so far as the cure of his 
gonorrhoea is concerned, and he will, very probably, soon return to 
his business, cured both of his clap and swelled testicle. Copaiba 
and cubebs have no curative action upon epididymitis, and I think 
it best to abstain from using them when this complication super- 
venes. 

There are two other modes of treating gonorrhoeal epididymitis 
which require a passing notice. The first is that proposed by M. 
Velpeau, and consists in puncturing the tunica vaginalis and evacu- 
ating the contained fluid, no matter how small its quantity. This 
procedure has already been recommended above, when the fluid has 
attained an appreciable amount. The peculiarity of M. Velpeau's 
practice lies in the frequency with which he employs it, even where 



TREATMENT. 135 

a few drops only escape from the incisions. He claims for this 
method that it gives immediate relief to the pain ; that it shortens 
the duration of the disease, and takes the place of leeches and other 
troublesome and expensive remedies. The frequency with which 
this procedure is resorted to appears to be confined to M. Yelpeau. 
Other surgeons deem it advisable only under the circumstances 
already indicated. The dread of the knife which patients laboring 
under this disease naturally have, is a strong objection to its fre- 
quent employment. As a general rule, it is safe, for in one case 
only, so far as I am aware, has it been attended with any unpleasant 
result. This was in a patient under the care of M. Montanier, 1 in 
whom excessive hemorrhage followed a simple incision into the 
tunica vaginalis, which was very difficult to control, and which even 
endangered life. Probably some scrotal artery of considerable size 
was wounded in the operation. 

The late M. Vidal (de Cassis) revived an operation which is said 
to have originated with a French surgeon by the name of Petit, 
who published a work on venereal in 1812. This operation is 
simply an extension into the substance of the testicle of the incisions 
recommended by Yelpeau. Yidal states that he first employed 
these incisions in swelled testicle when the body of the testicle was 
involved, to which form of the disease he gives the name of paren- 
chymatous orchitis. His design was, by dividing the tunica albu- 
ginea, to relieve the constriction exercised by this fibrous tunic 
upon its inflamed contents. Finding, as he says, that the operation 
was unattended by any unpleasant result, and that it relieved the 
pain and hastened resolution, he extended it to the more frequent 
cases in which the epididymis is alone attacked, and found the effect 
equally favorable. In his work on venereal, this author states that 
he has performed this operation with impunity in four hundred 
cases, and claims for it preference to all other modes of treatment. 
His directions as to the manner of performing it, are to incise the 
tunica albuginea with a bistoury or lancet passed through the scro- 
tum and tunica vaginalis to the extent of six-tenths of an inch (un 
centimetre et demi), and to penetrate the parenchyma of the testicle 
to the depth of less than three-tenths of an inch {de moins de moitie). 
Only one puncture of this kind is to be made. In spite of M. 
Yidal's testimony in its favor, we can hardly believe this operation 
entirely devoid of danger, especially since the recent report of four 

1 See the Gaz. des Hopitaux, 1858, p. 106. 



136 SWELLED TESTICLE. 

cases observed by a single surgeon, M. Demarquay, in which the 
substance of the testicle gradually oozed from the incision in fila- 
ments, and in three of which the testicle was totally lost. 1 If re- 
sorted to at all, it should probably be reserved for those cases in 
which it was first used, viz., where the body of the testicle is exten- 
sively implicated. 

Numerous other topical remedies have been recommended in 
gonorrhoeal epididymitis, but many of them are not worthy of 
mention. Inunctions of mercurial ointment upon the scrotum may 
relieve the pain, but are liable to cause salivation. They may 
be used with caution in those cases in which the acute symptoms 
have subsided, leaving chronic engorgement of the epididymis. 
The application of chloroform has been advised, but before affording 
ease it usually increases the pain and renders it almost insupportable. 

The active treatment by leeches and purgatives, above recom- 
mended during the acute stage of epididymitis, includes the best 
prophylactic measures that we can adopt to prevent any induration 
being left behind in the epididymis. If such be detected, however, 
the earlier it is attacked the better, for the chances of success are 
certainly superior, while the plastic material is not yet fully organ- 
ized. If the indurated epididymis is still abnormally sensitive to 
pressure, the application of a few leeches over the cord, repeated 
several times at intervals of a few days, will be found of service. 
A small quantity of mercurial ointment should be rubbed into the 
scrotum morning and night ; the genital organs should be well sup- 
ported by a suspensory bandage, and the bowels be kept free. 
Much is to be expected also from the internal administration of 
iodide of potassium, which is so powerful an agent in resolving 
inflammatory products generally. It is impossible to say how old 
an induration of the epididymis can be treated with hopes of suc- 
cess. M. G-osselin's cases show that they may disappear after exist- 
ing for several months, and it is not improbable that a cure may 
be effected after a much longer period. Where the epididymis 
on both sides is affected, the attempt should certainly be made, 
especially if the patient is young and intends to marry. It is a 
serious question whether the surgeon should inform him of the 
impotency which his disease entails, since the effect of this informa- 
tion upon his mind might possibly be most disastrous. 

1 British and For. Medico-Chirurg. Rev., Am. ed., Apr. 1859, from the Bulletin 
de Therapeutique, tome lv. p. 549. 



INFLAMMATION OF THE PEOSTATE. 137 



CHAPTER VII. 

INFLAMMATION OF THE PEOSTATE. 

ACUTE PEOSTATITIS. 

Acute prostatitis may be due to violence from sounds, catheters, 
or lithotrity instruments ; to the application of caustic to the deeper 
portions of the urethra ; to stricture, the irritation of a stone in the 
bladder, immoderate coitus, or excessive purgation; but by far the 
most frequent cause is urethral gonorrhoea. 

Gronorrhoeal prostatitis owes its origin to the extension of the 
inflammation from the urethral walls to the substance of the pros- 
tate gland; it occurs, therefore, at a time when the disease has 
invaded the deeper portions of the canal, and is consequently rare 
during the first two weeks of a gonorrhoea; resembling in this 
respect its more frequent congener, gonorrhoeal epididymitis. The 
accessory causes of the last mentioned disease, viz., highly irritant 
injections, forcible distension of the urethra in using a syringe, 
excessive exercise, alcoholic stimulants, exposure to cold and wet, 
and venery, may also contribute to the production of prostatitis. 
There is less ground for believing that this affection is occasioned 
by the use of copaiba and cubebs, unless in very immoderate 
doses. 

The earliest symptoms of an attack of prostatitis are an increased 
frequency in the desire to micturate, and a sensation of weight or a 
dull pain in the perineum. As the disease progresses, the calls to 
pass water become more and more frequent, while the stream is 
very small, is only forced out by prolonged straining, and is attended 
by a severe scalding sensation at the neck of the bladder; some- 
times only a few drops appear, or there is complete retention of 
urine. The bowels are generally constipated, though the patient 
is often led by a feeling of distension in the rectum to make fruit- 



138 INFLAMMATION OF THE PROSTATE. 

less efforts at stool ; and should defecation take place, the act excites 
severe pain. The system at large sympathizes with the local trou- 
ble, and general febrile excitement ensues. Exploration of the 
prostate by the finger in the rectum reveals abnormal sensibility 
and tumefaction of this organ proportioned to the severity of the 
disease; and a sound introduced into the urethra, upon reaching 
the prostatic region, meets with an obstruction and excites a degree 
of suffering that is with difficulty endured by the patient. 

Acute prostatitis may terminate in resolution, in suppuration, 
and, in rare instances, in gangrene. Several cases are recorded in 
which the inflammation has extended to the peritoneum, and in 
which death has ensued from peritonitis. 

Of the above modes of termination, suppuration, next to resolu- 
tion, is the most frequent. The formation of matter is not always 
announced by well-marked symptoms, but may be strongly sus- 
pected if, after the disease has been increasing in intensity for eight 
or ten days, the patient is seized with repeated chills followed by 
fever and general depression. It is possible, however, for an abscess 
to form without affording the least reason to suspect it. A case 
recently occurred at St. George's Hospital under the care of Dr. 
Pitman, in which prostatitis supervened upon an attack of gonor- 
rhoea, and terminated in suppuration and the death of the patient, 
with entire absence of rigors and the ordinary symptoms of ab- 
scess of the prostate. At the post-mortem examination, an exten- 
sive abscess, which had not been suspected during life, was found 
between the bladder and rectum. 1 

An abscess may be situated between the rectum and the gland, 
in the substance of the latter, or upon its urethral aspect. In the 
first two instances, a soft fluctuating tumor can be felt in the region 
of the prostate by the finger introduced into the rectum, especially 
if the gland be immovably fixed by a sound in the urethra. An 
abscess in the neighborhood of the urethra is more difficult of de- 
tection, except from its encroachment upon the canal, and its in- 
terference with the exit of urine and the introduction of a catheter. 

A prostatic abscess most frequently breaks upon the side of the 
urethra during the efforts of the patient to expel the urine or feces, 
or it is often perforated by the point of an instrument introduced 
for the purpose of exploration or catheterization ; sometimes it opens 

1 London Lancet, Am. ed., Jan. 1861, p. 69. 



ACUTE PKOSTATITIS. 139 

into the rectum, bladder, or cellular tissue of the pelvis ; or it may 
communicate with both bladder and rectum and give rise to a uri- 
nary fistula. In other instances the fluid contents are absorbed, and 
the abscess becomes surrounded by a kind of cyst which is filled 
with a semi-solid substance resembling a deposit of tubercle. 

Tkeatment. — The appearance, during an attack of gonorrhoea, 
of a frequent desire to pass the urine, and pain in the perineum, 
indicating that the inflammation has involved the neighborhood of 
the neck of the bladder, should lead the surgeon at once to abandon 
the use of astringent injections, copaiba and cubebs ; and, neglecting 
the urethral discharge for a time, to direct his whole attention to 
the more serious affection which has supervened. The patient 
should now observe the most perfect rest and quietude. If the 
symptoms be at all severe, from six to a dozen leeches should be 
applied to the perineum, and be followed by a hot bath at the tem- 
perature of 100°, which may be repeated with benefit several times 
in the twenty -four hours. Some authors recommend the application 
of leeches by means of an anal speculum to the anterior wall of the 
rectum, where contiguous to the inflamed gland. In the intervals 
of the baths the perineum should be covered with hot fomentations 
or poultices. 

Internally we may resort to those remedies, as the salts of potash 
and soda, which exert a beneficial effect upon inflammation of the 
neck of the bladder and its neighborhood, and which render the 
urine more dilute and mild in its character. The formula containing 
mucilage, bicarbonate of potash, and hyoscyamus, already given in 
the chapter upon urethral gonorrhoea in the male, is well adapted 
for the treatment of the disease we are now considering. The diet 
should be abstemious, consisting of gruel, mucilaginous drinks, milk, 
and farinaceous substances, at least in the early stages of the dis- 
ease ; at a more advanced period, and after suppuration has taken 
place, our utmost efforts may be required to sustain the strength of 
the patient by a nourishing diet and even tonics. 

Sleep should be secured by the exhibition of a Dover's powder 
at night. Mr. Adams speaks highly of warm enemata, consisting 
of four or five ounces of simple water or gruel, administered at bed- 
time, which are said to afford comfort to the patient, and to act as 
a fomentation to the inflamed gland. 1 

1 Anatomy and Diseases of the Prostate, p. 41. 



140 INFLAMMATION OF THE PEOSTATE. 

Complete retention of urine will require evacuation of the bladder 
by means of a catheter. When an abscess has formed and fluctua- 
tion can be distinctly felt by the finger in the rectum, a puncture 
may be made through the intestinal wall ; or when the collection of 
matter is most prominent towards the urethra, it may sometimes be 
opened by a conical sound introduced as far as the prostatic portion 
of the canal, while a finger within the rectum presses the tumor 
against the point of the instrument. This attempt, however, is by 
no means free from danger, and should never be made, unless the 
symptoms are urgent and the existence of matter in the neighbor- 
hood of the urethra highly probable. 

CHEONIC PEOSTATITIS. 

The preceding affection is that form of prostatitis which most 
frequently accompanies and originates in urethral gonorrhoea. 
Chronic prostatitis, on the contrary, is more commonly due to 
onanism, excessive venereal indulgence, or sedentary habits; and, 
although not unfrequently occurring in persons who have suffered 
from gonorrhoea, is in most cases less directly traceable to this 
affection. 

For a long period chronic prostatitis was confounded with irrita- 
tion and inflammation of the neck of the bladder, and was not 
recognized as a distinct disease until the publication of the admirable 
descriptions of it by Mr. Adams, 1 Mr. Ledwich, 2 and more recently 
by our distinguished countryman, Dr. Gross, of Philadelphia. 3 

Chronic prostatitis is most common in young men, and especially 
among those who lead a sedentary life, or who are the victims of 
masturbation. It is also met with in persons who have abused 
their sexual powers either in promiscuous intercourse or early 
married life. 

One of the most frequent and prominent symptoms of this affec- 
tion is a discharge of clear and transparent, or sometimes turbid, 

1 Anatomy and Diseases of the Prostate Gland. London, 1853. 

2 Dublin Quarterly Journal, Aug. 1857, p. 30. 

3 North Am. Med.-Chir. Rev., July, 1860. Dr. Gross describes this as a hitherto 
unknown affection under the name of " prostatorrhcea," but his account of it cor- 
responds in almost every particular with that given by Mr. Adams under the head 
of "prostatitis from onanism." The increased secretion of prostatic fluid is a 
mere symptom of irritation or inflammation of the gland, and it is therefore desir- 
able that the term prostatitis should be retained. 



CHRONIC PROSTATITIS. 141 

mucus from the meatus, which is found by the microscope to consist 
of: 1. "Morphous crystals of uric acid, or ammoniaco-magnesian 
phosphates; 2. Mucus-corpuscles; 3. Blood-disks; and 4. Epithelium 
cells," * either with or without a few pus-corpuscles. The discharge 
may be almost constant in its appearance and sufficient in quantity 
to stain the linen, or, more frequently, it is forced from the urethra 
by the pressure of the hardened feces during straining at stool, and 
is not perceptible at any other time. Most patients suppose that it 
consists of semen, from which it may be distinguished under the 
microscope by the absence of spermatozoa. Yery many of the cases 
of spermatorrhoea so-called are doubtless instances of this affection. 

In most cases, the frequency of micturition is more or less in- 
creased; the stream of urine is ejected without force ; the last drops 
dribble away, or are only expelled with considerable effort ; and a 
scalding sensation is felt in the urethra during and after the act. 

Pain and uneasy sensations are experienced in the perineum, 
thighs and lumbo-sacral region; there is often great irritation about 
the anus attended by haemorrhoids or eczema ; the bowels are con- 
stipated, and defecation difficult and painful ; the passage of an in- 
strument into the bladder excites severe pain as it passes through 
the prostatic region ; on examination per anum, the gland is found to 
be tumefied, sensitive on pressure, and sometimes indurated ; the 
patient is irritable and low spirited ; is incapable of mental or phy- 
sical exertion ; suffers from weakness, headache, and dyspepsia ; 
watches his symptoms with the greatest anxiety ; imagines that he 
is losing his memory, that he is impotent or affected with syphilis, 
and, in short, becomes a desperate hypochondriac. 

Independently of its action upon the nervous system, chronic 
prostatitis is not a serious, although a very obstinate disease. It 
never terminates in suppuration and abscess, nor in the chronic 
hypertrophy so common in old men. 

Mr. Ledwich has had an opportunity, in two instances, of becom- 
ing acquainted with the pathology of this affection; "one case oc- 
curred at the age of 18, the second at 30 ; both were well-marked 
examples of the disease, and succumbed to phthisis, but this latter 
had no connection with the urethral affection. The prostato-vesical 
plexus was full, and many of its branches varicose ; the capsule of 
the prostate adhered intimately to its surface, and, on slicing the 

1 Ledwich, op. cit. 



142 INFLAMMATION OF THE PROSTATE. 

gland, it seemed' soft, with large, open, venous branches on the sec- 
tion, from which blood exuded, whilst the whole gland exhibited an 
augmented volume; the mucous membrane of its urethral aspect 
was red, soft, thickened, and villous, whilst the ducts could be dis- 
tinguished with the unassisted eye; the uvula and trigonum vesicas 
were red and turgid, but the remainder of the bladder was healthy. 
I examined with some anxiety for the presence of tubercular deposit 
in the gland, but, although this morbid condition was often antici- 
pated, no evidence of any such structural lesion could be detected. 
The seminal ducts did not present any alteration as to size, their 
excretory orifices being discovered with the" greatest difficulty, the 
vesiculge seminales being full and swollen, but without any other 
abnormal appearance ; scrofulous tubercles existed in the epididy- 
mis, yet the testicles, although soft and small, were otherwise 
healthy." 

Treatment. — In most cases of chronic prostatitis, the patient is 
laboring under a combination of mental as well as physical symp- 
toms, and the treatment must be directed to the mind equally with 
the body. It is not sufficient in these cases to dash off a hurried 
prescription and dismiss the patient after five minutes conversation. 
The victim of mental more than physical suffering has for weeks or 
even months been brooding over his complaint during all his waking 
moments, not absolutely necessary to his daily occupation, exagge- 
rating each trifling symptom, entertaining the most gloomy fore- 
bodings of the future, and perhaps contemplating suicide. First of 
all, he needs a friend who can lead him, however reluctantly, to un- 
burden his mind of its sorrow. This load removed, he at once 
feels lighter and more hopeful. The surgeon's first object, there- 
fore, should be to gain his confidence by friendly yet manly conver- 
sation, lending a ready ear to the familiar story of the hypochondriac, 
encouraging him to feel that he has found a sympathizing friend as 
well as physician, and gradually and skilfully leading him from 
the depths of despondency to more rational views of his position 
and prospects in life. 

One great source of anxiety to the patient is probably the idea 
that the transparent viscid discharge which appears during strain- 
ing at stool, or is mingled with the last drops of urine, consists of 
semen. The surgeon is generally safe in assuring him of the con- 
trary, without special examination, since diurnal spermatorrhoea 



CHRONIC PROSTATITIS. 143 

without some degree of spasmodic action is exceedingly rare ; but 
any doubt upon the subject may be removed by placing a drop of 
the fluid under the microscope which will probably confirm his 
assurance by showing the absence of spermatozoa. 

In many cases, however, chronic prostatitis is really complicated 
with seminal emissions, taking place at night, with greater or less 
frequency. In such instances, the most substantial meal in the 
twenty-four hours should be taken about noon, the supper should 
be light, and food and drink entirely avoided in the evening ; the 
bedchamber should be well ventilated, a hair mattress preferred to 
a feather bed, and much covering avoided ; and the patient should 
be directed to sleep upon his side instead of upon the back, and to 
rise as soon as he wakes, seminal emissions occurring most fre- 
quently during the semi-consciousness of the early morning nap. 
Tobacco in every form should be prohibited, since it not only in- 
creases the general irritability of the nervous system, but appears 
to have a direct influence upon the genital organs in diminishing 
their tone and thus favoring seminal emissions. Above all, the 
mind of the patient should be distracted from his complaint by con- 
stant occupation, and the general health be promoted by a plain 
but nourishing diet, and by daily out-door exercise, not carried to 
fatigue. Spermatorrhoea is not unfrequently associated with, and 
in a great measure dependent upon, the presence of varicocele, phy- 
mosis, or an excessively elongated prepuce, the removal of which, 
by an operation, is essential for the relief of the nocturnal emis- 
sions. It is natural to suppose that any local source of irritation 
will keep up the excitability of the genital organs, and this sup- 
position is abundantly confirmed in practice. I have met with a 
number of instances in which the relief afforded to spermatorrhoea 
by circumcision or an operation for varicocele was most decided 
and unquestionable. 

There is a fact which is generally unknown to the subjects of 
spermatorrhoea, and a knowledge of which affords great relief from 
mental anxiety and thereby assists recovery. It is this, that noc- 
turnal seminal emissions occasionally occur to nearly all unmarried 
men, especially between the ages of fifteen and twenty-five, or even 
later, and are not inconsistent with robust health. Indeed, their 
repetition as often as once or twice a week, provided the patient is 
aware of no debility or other ill effect in consequence, need cause 
no apprehension. After the age of twenty -five, the excitability of 



144 INFLAMMATION OF THE PROSTATE. 

the genital organs gradually diminishes, and involuntary seminal 
emissions decrease in frequency or cease altogether. 

The charlatan finds it for his interest, by every means in his 
power, to heighten the fears of the subjects of spermatorrhoea ; the 
true surgeon equally endeavors to allay them, and, without ex- 
ceeding the bounds of truth, may give positive assurances of recovery 
to every patient in early life (say under the age of 25) and of a 
naturally good constitution, upon the following conditions : 1. That 
any habits of self abuse which may have been indulged in be totally 
abandoned ; 2. That he cease to think only of himself and his com- 
plaint, and find some healthy occupation for his mind and body. 
At the same time he should be informed that he is not to expect 
immediate and complete relief; that his emissions will still for a 
time recur, although at gradually increasing intervals; but that, if 
he will only persevere, his ultimate recovery is certain. If he can 
be brought to think lightly of the emissions at the time of their oc- 
currence, trusting in the surgeon's assurance that they are a merely 
temporary evil, a cure is well nigh accomplished. 

The numerous popular works which have appeared upon mastur- 
bation and seminal emissions, most of them written by quacks with 
the basest of motives, have done an immense deal of mischief by 
inducing that state of mind in the reader best calculated to keep up 
his disease. The purest and most unexceptionable work of this 
class that I have ever seen, was written by a noble physician and 
philanthropist recently at the head of one of our Insane Asylums ; 
but only one edition was allowed to appear, because the author be- 
came convinced that the most guarded treatise upon this subject 
was not free from danger. I am happy to quote this high authority 
in confirmation of the statement above made, that seminal emissions 
occurring in youth very rarely produce disastrous results, provided 
the habit upon which they most frequently depend is entirely aban- 
doned. The frequent co-existence of seminal emissions with chronic 
prostatitis and the similarity of the patient's mental condition, re- 
quiring, in the two diseases, the same treatment directed to the mind, 
will excuse the apparent digression in the above remarks. 

In addition to the general hygienic means above recommended, 
most cases of chronic prostatitis require the administration of iron, of 
which the tincture of the chloride, in the dose of twenty drops after 
each meal, is undoubtedly the best preparation. I have also ob- 



CHKONIC PROSTATITIS. 145 

tained favorable results from a solution of strychnine in dilute phos- 
phoric acid : — 

R. Strychniae gr. j. 

Acidi phosphorici diluti |iij. 
M. 
A teaspoonful three times a day. 

The large proportion (about two-thirds) of muscular fibre enter- 
ing into the composition of the prostate, explains why affections of 
this body are but slightly amenable to those remedies, as iodine, the 
action of which is so favorable upon organs strictly glandular. 

Chronic inflammation of the prostate is perpetuated by the con- 
stipated state of the bowels and consequent straining at stool which 
usually attends it, and which should, therefore, be obviated by lax- 
atives or enemata; but aloes, which is a constituent of most of our 
pharmaceutical preparations for this purpose, should be avoided, on 
account of its well-known tendency to produce congestion of the 
hemorrhoidal vessels. Saline cathartics may be administered in 
small doses in the morning on rising ; but I much prefer enemata 
of cold water, taken immediately before the usual time of going to 
stool, which are followed by a loose evacuation unattended by strain- 
ing, and which prevent the discharge of prostatic fluid. In cases 
complicated with gleet, and in the absence of acute inflammation, 
benefit may be derived from weak astringent urethral injections. 

As a general rule local applications may be dispensed with, and 
are so far objectionable as they tend to direct the thoughts of the 
patient to the seat of his disease. Yet when decided tenderness of 
the prostate is found on examination per anum, the repeated appli- 
cation of leeches or blisters to the perineum will prove beneficial. 
The late Dr. J. C. Warren, of Boston, highly recommended in these 
cases the use of the cold douche to the perineum. It is only in 
extreme cases, which have resisted milder methods of treatment, 
that cauterization of the prostatic portion of the urethra, repeated 
at intervals of a week or ten days, should be resorted to. Moderate 
sexual indulgence is found to relieve the morbid irritability of the 
genital organs, and matrimony, when practicable, should be recom- 
mended to those who are single. 

10 



146 INFLAMMATION OF THE BLADDER. 



CHAPTER VIII. 

INFLAMMATION OF THE BLADDER. 

Cystitis is a less frequent complication of gonorrhoea than pros- 
tatitis, but occasionally occurs as a consequence of the extension of 
the inflammation along the continuous mucous surface common to 
the urethra and bladder. It has also been attributed in rare instances 
to the gohorrhoeal discharge finding its way ; or being forced into 
the bladder and there lighting up inflammation similar to that affect- 
ing the urethral walls. A case of this kind is reported in the Arch. 
Gen. de Medecine, 1 in which cystitis suddenly supervened after using 
a simple' emollient injection. All those causes which aggravate the 
urethritis may concur in exciting cystitis, among which the abuse 
of injections should be included. 

In this disease the highly sensitive condition of the inflamed blad- 
der prevents the retention of more than a few drops of urine, and 
the calls to urinate are very frequent and urgent. There is also 
pain in the hypogastric region radiating towards the perineum, and 
in the direction of the kidneys along the course of the ureters; 
together with tenderness upon pressure above the pubes. The urine 
is high colored, sometimes tinged with blood, and mixed with stringy 
mucus or pus. In some instances complete retention takes place 
from a loss of contractility in the vesical walls, and the distended 
bladder can be felt rising above the symphysis pubis and rendering 
the abdomen more prominent than natural. When the bas-fond of 
this organ is chiefly involved, there is frequent desire to go to stool 
and rectal tenesmus ; while in some instances the valvular outlets 
of the ureters are closed by the tumefaction of the vesical walls, 
giving rise to distension and dilatation of the ureters, and severe 
pain along their course and in the region of the kidneys. General 
febrile excitement is present at the commencement, but if the disease 

1 Tome xiii. p. 454, 1829. 



TREATMENT. 147 

proceed to a fatal termination, great prostration soon sets in ; marked 
by a small quick pulse, dry tongue, clammy perspiration, hiccough, 
sleeplessness, and delirium. 

In many cases of gonorrheal cystitis the inflammation is confined 
to the neck of the bladder, when the retention of urine is more 
obstinate, the difficulty in passing a catheter greater, and the symp- 
toms generally more acute than if the whole viscus be involved. 
According to Lallemand, inflammation confined to the neck of the 
bladder may be recognized by the peculiar phenomena attending 
catheterization. " In proportion as the instrument advances through 
the curved portion of the urethra, the pain of its introduction 
increases, and, when it reaches the vesical neck, becomes intolerable. 
The neck of the bladder closes as the catheter approaches and is 
pushed on before it, so that the instrument may appear to have 
entered the bladder ; but, if left to itself, is partially forced out of 
the canal by the restoration of the neck to its natural position. 
Under these circumstances nothing would be gained by using force, 
which, moreover, is capable of doing much harm. The catheter 
should be left in place until the spasmodic contraction has passed 
off; when the vesical neck opens of itself and appears to draw the 
point of the instrument into the bladder by a kind of suction pro- 
cess accompanied by a slight to-and-fro movement. The pain at 
this time is especially severe; it appears to the patient as if the 
catheter were touching a raw surface; and considerable difficulty is 
experienced in withdrawing the instrument, owing to the contraction 
of the vesical neck around it." 

Acute cystitis most frequently terminates in resolution ; though 
sometimes, in the chronic form of the disease, in abscess situated in 
the substance of the vesical walls, or between the bladder and rec- 
tum; in hypertrophy, ulceration, rupture, or even gangrene. If 
rupture take place, the escape of the urine into the pelvic cellular 
tissue or peritoneal cavity, soon leads to a fatal termination. 

Treatment. — The treatment of acute cystitis consists in the 
application of cups or leeches to the perineum and hypogastric 
region, prolonged immersion in warm hip-baths, hot fomentations 
and poultices to the hypogastrium, warm opiated enemata, and the 
internal administration of mucilaginous drinks in small quantities, 
with the addition of the nitrate or bicarbonate of potassa and hen- 



148 INFLAMMATION OF THE BLADDER. 

bane. Catheterization is required for the relief of retention of 
urine, but should not be performed with unnecessary frequency, for 
fear of increasing the inflammation ; and a permanent instrument 
is objectionable for the same reason. At the same time, the urine 
is rendered acrid and irritating by the admixture of mucus and 
pus, and should not be left to accumulate in large quantities. 



GONORRHOEA IN WOMEN". 149 



CHAPTER IX. 

GONORRHOEA IN WOMEN. 

The mucous membrane of the genital organs is far more exten- 
sive in the female than in the male. Besides lining the urinary 
canal and the vulva — parts corresponding to the urethra and balano- 
preputial fold in man — it is continued over the walls of the vagina, 
where its surface is increased by numerous folds, and, reflected over 
the os tincse, extends into the cavities of the cervix and body of the 
uterus. Any portion of this extensive surface may be attacked by 
catarrhal inflammation, which, according to its seat, is called gonor- 
rhoea of the vulva, urethra, vagina, or uterus. Some of these parts 
are more frequently affected than others. Thus, gonorrhoea of the 
vagina is more common than that of the urethra or vulva, and 
gonorrhoea of the uterus is the least frequent of all. It is rare for 
all the different portions of the female genital organs to be attacked 
together, though two or more are, in many instances, combined as 
the seat of gonorrhoeal inflammation. The manner of union appears 
to be chiefly determined by the anatomical relation of the parts. 
Thus, when the vulva is affected, the urethra and lower portion of 
the vagina are likely to be involved ; while, on the other hand, the 
upper part of the vagina and uterus are not unfrequently implicated 
together. 

Causes. — Gonorrhoea is a much less common disease in women 
than in men. This may be accounted for by several reasons. The 
mucous membrane of the vagina is less sensitive than that of the 
male urethra; it receives no little protection from the sebaceous and 
mucous secretions which constantly cover it ; the size of the passage 
is such that it can be readily cleansed ; and the urethra, in conse- 
quence of its being but very slightly concerned in the sexual act, 
and of the situation of its meatus, is less exposed to contagion. But 
another reason, and one perhaps of still greater weight, is to be found 



150 GONOREHCEA IN WOMEN. 

in the absence in men of those chronic discharges, the presence of 
which in women is so fruitful a cause of urethritis in the opposite 
sex. When speaking of the causes of gonorrhoea in the male, I 
endeavored to show that it is frequently due to the irritation pro- 
duced by a leucorrhoeal discharge, by the menstrual flow, or by the 
normal secretions of the female genital organs. Women, in sexual 
intercourse, are not exposed to these exciting causes of gonorrhoea. 
In a condition of health, there is no secretion about the male genital 
organs capable of exciting inflammation in the female ; while during 
the acute stage of gonorrhoea the pain excited by turgescence of the 
penis is generally sufficient to deter from coitus, and even in cases 
of gleet, the amount of the discharge is so small, the urethra so 
frequently cleansed by the passage of urine, and the vagina so well 
protected by sebaceous matter, that intercourse may often take place 
without much exposure to the woman. Owing to these circumstances, 
women more frequently communicate than receive gonorrhoea. 

It would seem to be a fair deduction from the foregoing, that, 
taking a given number of gonorrhoeal cases in the two sexes, more 
are due to infection in women than in men; and such I think is 
unquestionably the fact. But while assigning to direct contagion 
the first place in the etiology of the gonorrhoea of women, other in- 
fluences must not be overlooked. These, however, are less appreci- 
able in the female than in the male. The history of women seeking 
advice for gonorrhoea can rarely be ascertained with certainty, or 
their disease traced with accuracy to its source. It is notorious' 
that a woman often receives the embraces of several men within a 
short space of time, and there are many reasons for her concealing 
important facts which a man would readily confide to his physician. 
It is, therefore, only under peculiar circumstances that we can 
satisfactorily ascertain the origin of gonorrhoea in women ; still, op- 
portunities for such investigation do sometimes occur, and, in several 
which I have met with, it was evident that the disease was due to 
other causes than contagion. Thus, I have known intercourse with 
a healthy man to excite acute and extensive inflammation of the 
genital organs in women suffering from leucorrhoea and congestion 
of the cervix, especially if the stimulus of liquor was added to that 
of coitus. In such cases, chronic may readily be transformed into 
acute inflammation, in the same way as a gleet in man may be 
changed into a clap. In some instances, I have had reason to 
believe that the frequent repetition of the sexual act has produced 



CAUSES. 151 

gonorrhoea in women free from any previous disease, and it is a 
well established fact that a purulent discharge sometimes follows 
the first exercise of marital rights, although there may have been 
no laceration of the female genital organs. In general, the causes 
of gonorrhoea in women, independently of contagion, may be enume- 
rated as follows: Immoderate sexual intercourse, violence, mastur- 
bation, the presence of vegetations, syphilitic or other eruptions, 
errors of diet, ascarides in the rectum, and the external influences 
of cold, moisture, etc. 

Many women have, during pregnancy, a muco-purulent discharge, 
which usually makes its appearance after the fourth or fifth month, 
though sometimes before, and chiefly affects the upper portion of the 
vagina. An examination of the vaginal mucous membrane reveals 
the existence of numerous granulations, similar to those observed 
also in some cases of vaginitis from contagion. Cazeaux states that 
this discharge may produce disorder of the digestive functions, as 
shown by the coexistence of gastralgia, which is more or less severe 
according to the intensity of the vaginitis. 1 The discharge usually 
disappears spontaneously after the termination of gestation. 

Vaginitis may be attendant upon scarlet fever, or it may follow 
this and other exanthemata as a sequela. 2 

Yery young girls may be attacked with inflammation of the genital 
organs, producing a copious purulent discharge from the vulva, 
and sometimes from the vagina also, the cause of which has often 
been misapprehended. It has been supposed that the disease was 
contracted from men who had been seen to caress or fondle them, 
and innocent persons have been arrested and tried on this charge. 
No one in such cases has done more for the honor of our profession 
and for the cause of humanity than Mr. "Wilde, of Dublin, who has 
repeatedly come forward when the accused party was about to be 
convicted for an offence which he never committed, has shown the 
groundlessness of the charge and proved his innocence. In most 
cases, the discharges in question are no more venereal in their nature 
than the otorrhcea which is so common in children. Their predis- 
posing cause is hereditary cachexia, or, as it is commonly called, a 
strumous diathesis. The exciting cause may be deficient cleanli- 
ness, derangement of the digestive functions, the irritation of teeth- 

1 Traite de l'Art des Accouchements, 4e edition, p. 317. 

2 Cormack, London Journal of Medicine, Sept., 1850, p. 872; and Barnes, Medi- 
cal Gazette, July 12, 1850, p. 65. 



152 GONOKKHCEA IN WOMEN. 

ing, and the presence of ascarides in the rectum, or within the vulva, 
where they may have found their way from the gut. Such dis- 
charges are contagious when applied to the ocular conjunctiva, and 
not less so, in all probability, if brought in contact with the genital 
organs of a second person ; thereby proving that the contagiousness 
of gonorrhceal matter depends upon the seat of the disease, and not 
upon the presence of a specific poison necessarily transmitted from 
one individual to another. 

Symptoms. — The initiatory symptoms of gonorrhoea in women 
are often obscured, in the rare instances afforded for their examina- 
tion, by the previous existence of a leucorrhoeal discharge. They 
do not differ from the early symptoms of inflammation of other 
mucous membranes, and consist in the gradual development of 
swelling, redness and tenderness, and an increase of, and change in, 
the secretion of the part. The discharge varies in consistency and 
color as in gonorrhoea in the male. It is at first transparent and 
mucous, then muco-purulent, and finally, when the disease has 
attained its height, thoroughly purulent. When secreted by the 
vagina it is acid, fluent, creamy, and readily removed from the sur- 
face ; when derived from the cavity of the cervix, 1 without being 
mixed with the acid matter of the vagina, it is alkaline, nearly 
transparent, tenacious like the white of egg, and very adhesive. 
Examined under the microscope, the vaginal secretion is found to 
consist of pus- corpuscles, mucus, an abundance of epithelial scales 
and flakes of epithelium in masses; while the viscid plug drawn 
from the cervix, which, as shown by Dr. Tyler Smith, is glandular 
in its structure, exhibits mucus-corpuscles, oil-globules and purulent 
matter. The consistency and yellowish color of the vaginal secre- 
tion are dependent upon the quantity of organized elements it con- 
tains. The thicker it is, the more opaque, and the more resemblance 
it bears to cream or pus, the greater the quantity of pavement epi- 
thelium and pus-globules, as shown by the microscope. 2 

M. Donne has also called attention to the presence of a small 
infusorial animalcule which he at first supposed to be pathogno- 
monic of gonorrhceal vaginitis. He has since renounced this opinion, 

1 The most convenient method of collecting the cervical secretion for the pur- 
pose of examination, unmixed with the vaginal mucus, is by means of Lalle- 
inand's porte caustique, uncharged. 

2 Pathology and Treatment of Leucorrhoea, Phil, ed., 1855, p. 122. 






GONORRHCEA OF THE VULVA. 153 

but still asserts that the Trichomonas is not seen in healthy vaginal 
mucus, but only when there is a large admixture of pus-globules. 
Farther researches by Kolliker and Scanzoni 1 would show that it is 
never present in the secretion of the cervix, so that it cannot be a 
mere cell of ciliary epithelium, and these authors state that there 
can be no doubt of its independent animal nature. It was first 
found by them in pregnant women, and, after their attention was 
called to it, in more than half the women whom they examined. 
Hence it cannot be considered as characteristic of gonorrhoea. Still, 
it is never met with in perfectly healthy mucus, destitute of pus- 
globules. It appears to depend upon certain changes in the vaginal 
secretion, and is not developed to any extent except in mucus which 
is clearly abnormal. 2 

Traces of a discharge from the genital organs are to be sought 
for chiefly upon the posterior portion of a woman's linen, and not 
upon the anterior. The absence of any external evidence of disease 
does not, however, prove her sound ; since the upper portion of the 
vagina may be inflamed and the secretion be retained within the 
vulva. The symptoms of gonorrhoea in women vary according to 
the part affected, and it is convenient to make a corresponding divi- 
sion in their description, recollecting, at the same time, that the 
different forms may be more or less combined in a given case. 

Gonorrhoea of the vulva is less common than that of the vagina, 
and, in many cases, is secondary to the latter, being produced by 
contact with the discharge flowing from above. It is, however, often 
primary, and is that form which is commonly met with as the result 
of violence, or the presence of vegetations and syphilitic or other 
eruptions, as chancres, mucous patches, etc. The gonorrhoea of 
young girls, already referred to, is also, in most cases, vulvar. 

The patient's attention is early attracted to the part by a sensation 
of heat and pruritus. On examination, the mucous membrane is 
found to be reddened, tumefied, and more moist than natural. As 
the disease advances the discharge increases in quantity and becomes 
muco-purulent, or purulent, and very offensive. The labia and 
nymphas are swollen to such a degree that it is almost impossible 
to expose the orifice of the vagina. If the nymphae be naturally 

1 Das Secret d. Schleimliaut d. Vagina und des Cervix Uteri. Scanzoni's Bei- 
trage, Bd. ii. p. 128. Wurzburg, 1855. 

2 Traite Pratique des Maladies des Organes Sexuels de la Femme, par F. W. dk 
Scanzoni ; traduit de rAllemand, Paris, 1858, p. 452. 



154: GONOEEHCEA IN WOMEN. 

large ; they may swell to such, an extent as to protrude beyond the 
labia and become constricted; a condition which may be compared 
to paraphymosis. The mucons membrane may be deprived of its 
epithelium in patches, identical in character with the superficial 
excoriations of balanitis. The inflamed parts are exceedingly sen- 
sitive to the slightest touch or pressure, and motion is very painful. 
The last drops of urine fall upon the excoriated surface and give 
rise to severe scalding. The discharge collects in the hair on the 
mons veneris and upon the external surface of the labia, and flows 
upon the integument of the perineum, and upon the upper portions 
of the thighs. Wherever it remains for any length of time it irri- 
tates and inflames the skin, which soon assumes an erythematous or 
even excoriated condition, and itself secretes an acrid humor. If 
the discharge comes in contact with the anus, as is very likely to 
occur when the patient lies upon the back, it may produce irritation 
of the rectum, attended by frequent desire to go to stool, pain on 
the passage of the feces, and sometimes slight diarrhoea. 1 

The sexual desires are often heightened, and amount at times to 
nymphomania, but coitus is attended with severe pain, if it even be 
possible. No other form of gonorrhoea in women equals this in 
the suffering which it occasions. This is partly owing to circum- 
stances already mentioned, and partly also to the great sensibility 
possessed by the vulva in common with other outlets of mucous 
canals. The general system sometimes sympathizes with the local 
disease, and the patient is found to be hot and feverish. All cases 
of vulvar gonorrhoea are not, however, so severe as that just de- 
scribed. Instances occur in which there is but little redness, tume- 
faction, or sensibility, and merely an increase of the secretion of the 
part; and the symptoms may vary all the way from this mild cha- 
racter to the intensity of the above description. 

The anatomy and pathology of the glandular apparatus of the 
female genital organs have been admirably given by M. Huguier, 2 
and no account of vulvitis would be complete without including a 
description of the changes which take place in these bodies. The 
vulva is abundantly supplied with sebaceous and muciparous folli- 
cles, which are lined by a prolongation of the mucous membrane. 
Travelling along this continuous surface the inflammation readily 

1 Baum&s, Precis sur les Maladies Veneriennes, t. ii. p. 163. 

2 Memoires de l'Academie de Med., 1850, p. 529. 



GONORRHOEA OF THE VULYA. 155 

gains access to the interior of the follicles, which soon pour out a 
thick purulent secretion from their mouths. 

The entrance to the vagina is also provided with two larger and 
more deeply situated secretory organs, which, although noticed by 
several anatomists subsequent to the seventeenth century, were 
comparatively unknown up to quite a recent date. These glands 
were first discovered by Duverney in the cow, and afterwards by 
Bartholin in woman, but, having been sought for in vain by Haller, 
they were entirely forgotten, until attention was again called to 
them, in 1840, by Tiedemann, 1 of Heidelberg, and by M. Huguier, 
of Paris, in 1850. They are now known by the name of Duverney 's, 
Bartholin's, Cowper's, or the vulvo-vaginal glands. They are situ- 
ated, one on either side of the entrance to the vagina, in the trian- 
gular space, bounded by the ascending ramus of the ischium, the 
vaginal orifice, and the transversalis perinasi muscle, and are covered 
by the superficial perineal fascia, and some fibres of the constrictor 
vaginae. Their size varies in different subjects, and they appear to 
be largest in women addicted to sexual intercourse. When most 
developed their diameter usually measures about six-tenths of an 
inch. They are conglomerate glands, consisting of congeries of 
small tubes, surrounded by a common envelope, and during the 
act of coitus, pour out a copious secretion of albuminous fluid, by 
means of a duct six or seven lines in length, opening just in front 
of the hymen, or near the lateral and posterior carunculse myrti- 
formes, which often conceal its orifice. 

The inflammatory process may invade this duct, and the gland 
beyond it, in the same manner that it does the superficial follicles ; 
and when suppuration has taken place, if the matter do not find 
free exit through the natural outlet of the gland, an abscess is 
formed either within the dilated duct, or in the substance of the 
gland itself; the former being generally the case when gonorrhoea 
is the exciting cause. 

Kow, abscesses in the neighborhood of the vulva are quite com- 
mon in cases of vulvitis, and though some of them are situated in 
the submucous cellular tissue, yet most of them are of the character 
above described, and are seated in the vulvo-vaginal gland or duct. 
A frequent and peculiar feature which marks them, is the facility 
with which, having once emptied themselves, they again fill up, on 

1 Von den Duverneyschen Drusen; Heidelberg, 1840. 



156 GONOKRHCEA IN WOMEN. 

the occurrence of any slight cause, as a return of the menstrual 
period, indulgence in sexual intercourse, exacerbation of the vulvar 
inflammation, etc. This circumstance has led some authors to the 
erroneous conclusion that these abscesses are surrounded by a true 
cystic wall, whereas their envelope continues to be, as at first, either 
the dilated duct or gland, which, to a certain extent, performs the 
office of a cyst. These glandular abscesses, however, may generally 
be recognized without much difficulty. The patient complains of 
a "swelling" in the vicinity of the vulva, which, on examination, is 
found to occupy the lower third of the labium, and borders upon 
the posterior commissure. The affected side is more prominent 
than its opposite, and the labium is pear-shaped, with its broader 
extremity directed backwards and inwards towards the median 
line; the integument on its external aspect preserves its normal 
color, and is free and movable, while the internal surface of mucous 
membrane is red and adherent to the tumor. The part is exceed- 
ingly sensitive to the touch, and the patient can neither walk, stand, 
nor sit, without difficulty, owing to the pain excited by the slightest 
pressure. The contents of the tumor are occasionally discharged 
through the normal duct of the gland, but, unless art intervene, the 
abscess usually bursts in the neighborhood of the glandular orifice, 
and very rarely on the external or integumental surface of the 
labium. M. Huguier contradicts the statement made by Vidal and 
other authors, that a recto-vaginal fistula is liable to form. This 
never occurs, according to the first named surgeon, if the rectum 
be in a sound condition. The frequent recurrence of abscesses of 
the vulvo-vaginal gland, or duct, is a source of great annoyance to 
women of the town, when suffering from chronic inflammation of 
the vulva. 

Dr. Salmon 1 has called attention to certain cases of gonorrhoea, 
in which the vulvo-vaginal gland and duct are alone affected ; the 
remainder of the genito-urinary organs retaining their normal con- 
dition. According to this surgeon, this affection is quite common, 
and especially so among young prostitutes, in whom it would seem 
to be due to the irritation of coitus upon parts as yet tender. The 
patient experiences no pain or inconvenience, and an examination, 
such as is ordinarily made, might lead to the conclusion that the 

1 Med. Times and Gaz., Dec. 23, 1854, p. 646, quoted from L'Union Medicale. — 
Braithwaite's Retrospect, Part 31, p. 208. 



VAGINITIS. 157 

genital organs were sound; but if the labium, on one or both sides, 
be firmly pressed against the ramus of the ischium, the gland, which 
is not perceptible to the touch in a state of health, may be felt as a 
moderately firm tumor, and its muco-puriform contents are seen to 
escape from the orifice of the duct. Dr. Salmon is of the opinion 
that vulvo-vaginal gonorrhoea will explain many cases in which a 
clap is contracted from a woman apparently healthy. Farther 
researches, however, are requisite to establish beyond a doubt the 
statement, that it is a common occurrence for gonorrhoea to affect 
primarily and exclusively the parts in question; although, after the 
subsidence of an attack of vaginitis or vulvitis, the inflammation 
may undoubtedly lurk for an indefinite period in the vulvo-vaginal 
gland and duct. 

Vaginitis is more common than any other form of gonorrhoea in 
women. The whole extent, or only a portion of this passage may be 
inflamed. The lower part is more or less implicated in most cases 
of vulvitis, while frequently the upper part is alone involved, and 
the woman might be supposed free from disease, if not examined 
with the speculum ; especially as, from the comparative insensibility 
of the upper portion of the vagina, her sensations are an unreliable 
index of its condition. Ricord states that the posterior wall of the 
vagina is more frequently affected in leucorrhoea, and the anterior 
wall in gonorrhoea. 

The modern application of the speculum to the study of venereal 
diseases (for which we are indebted to Ricord) has rendered an affec- 
tion, which was before obscure and of difficult diagnosis, at once 
clear and easily recognizable; and the zeal, of late years, brought 
to the pathological investigation of the female genital organs, has 
induced many observers to describe the lesions of vaginitis with 
great minuteness and detail. It is not to be regretted that these 
lesions have been subjected to so severe a scrutiny, although they 
have for this reason acquired an unmerited degree of importance, 
since it has been shown that they are characterized by no features 
sufficiently peculiar to indicate their venereal origin, and that they 
are, in nearly all respects, identical with the more familiar morbid 
appearances of other mucous membranes, as the conjunctiva oculi, 
the lining membrane of the mouth, ear, etc. 

The speculum should not be employed during the acute stage of 
vaginitis, as it is likely to excite severe pain and irritate the in- 
flamed tissues. The presence of the catamenia is also a contra- 



158 GONORKHCEA IN WOMEN. 

indication to its use. The ordinary cylindrical instrument, made 
of glass and coated with a layer of India rubber, is of easy intro- 
duction, and is generally sufficient for the examination of the vagina 
in suspected cases of gonorrhoea, but when it is desired to make 
local applications, or when thorough exposure of all the recesses of 
this passage is requisite in order to discover if any concealed chan- 
cre be present, a valvular speculum should be preferred. In order 
to remove the discharge which may obstruct the field of vision, the 
surgeon should provide himself with several swabs, which may be 
conveniently made by winding cotton wadding around the end of 
a thin splinter of wood. The patient may lie in the "obstetric 
position" upon her left side, or, as I prefer, upon her back, with the 
knees drawn up ; and delicacy requires, even when treating a woman 
of the town, that she should be covered with a sheet. 

When the vaginitis is intense and seen at an early period, a 
portion or the whole of the vaginal walls may be found red, hot, 
and dry, and entirely destitute of moisture. Eicord states that 
in several instances he has seen this condition finally terminate in 
resolution without the slightest discharge appearing at any time. 
Similar cases of dry or erysipelatous gonorrhoea have been reported 
as occurring in men, although the impossibility of examining the 
internal surface of the urethra throughout its whole extent has left 
them open to criticism. Generally, however, this dry condition of 
the vagina, if present at the outset, is succeeded in the course of 
twenty-four hours by the appearance of a discharge, which, at first 
transparent, afterwards undergoes changes similar to those which 
occur in gonorrhoea in the male ; and when the disease has attained 
its height, the vaginal walls are bathed with offensive purulent 
matter of a creamy or greenish color, or sometimes streaked with 
blood. Before proceeding with the examination, the field of the 
speculum must be cleared from the discharge by the assistance of 
the swabs of cotton- wadding, when the mucous membrane will be 
exposed. This surface is found to be red and tumefied. The red- 
ness varies in intensity and also in extent. It is sometimes uniform 
and at others arranged in spots or striae. Frequently patches are 
seen from which the epithelium has become detached, forming 
superficial abrasions similar to those met with in balanitis, or re- 
sembling blistered surfaces. Another condition which is at times 
met with has received the name of granular vaginitis. It consists 
in a development of the vaginal papillae, which project above the 



VAGINITIS. 159 

surrounding surface, and are readily recognized by their darker red 
color. These granulations are most frequently observed in the 
upper part of the vagina, where they may exist in large numbers 
covering the whole surface, or they may be merely scattered here 
and there. They have been erroneously regarded by Dr. Deville as 
peculiar to the vaginitis of pregnant women. 1 They are analogous 
to the granulations which are so common upon the palpebral con- 
junctiva. Eicord says that, in one case of vaginal gonorrhoea, he 
observed an eruption presenting every appearance of herpes phlycte- 
nodes situated upon the deeper portion of the vagina, and Ashwell 
speaks of " herpetic pustules," which by bursting form ulcers. 

In addition to the above symptoms, vaginitis is characterized by 
increased heat and sensibility. The former may be verified by 
introducing a finger within the vagina, when the parts will be felt 
to be much hotter than natural. The degree of sensibility varies, 
and is greatest when the vulva is also involved. In such cases, it 
is generally quite impossible to introduce a speculum owing to the 
pain which it excites ; but when the disease is confined to the vagina 
this instrument may often be employed without causing much suf- 
fering. During the course of vaginitis, there is often a frequent 
desire to pass the urine, and dull pain is felt in the hypogastric 
region, owing to sympathy excited on the part of the bladder. 

Gonorrhoea of the vagina rarely continues any length of time 
without extending to the mucous membrane covering the cervix, 
which may exhibit lesions identical with those now described, but 
more especially patches of superficial abrasions. Gonorrhoea of the- 
uterus is commonly confined to the cavity of the cervix. It is- 
sometimes secondary in this situation, being occasioned by the 
extension of the disease from the vagina, while at other times it is 
primary, and if the patient be examined at a sufficiently early 
period, the parts may be found in a perfectly healthy condition 
until the uterus is exposed when the lips of the os are seen to. be 
tumefied and red, the cervix congested and enlarged, and its cavity 
filled with tenacious and transparent muco-purulent matter. This 
secretion owes its transparency to the alkali which it contains. It 
becomes curdled and opaque when mixed with the vaginal acid, 
and hence cannot always be recognized after it has descended into 
the vagina or is discharged from the vulva. The fact that gonor- 

1 Archives Generales de Med., 4e serie, vol. v. p. 305. 



160 GONORRHCEA IN WOMEN". 

rhoea confined to the cervix uteri may readily be overlooked, may 
explain some of the cases in which a clap is derived from an appa- 
rently healthy woman. 

The acnte stage of vaginitis rarely continues longer than a week 
or ten days, and may be of much shorter duration. As the acute 
symptoms subside, the pain and difficulty of motion are diminished, 
The discharge becomes less copious and purulent, and the redness 
and tumefaction of the tissues gradually disappear. After this 
partial advance towards recovery, however, the disease often lingers 
for an indefinite period, and is extremely difficult to eradicate. The 
vaginal walls may seem to have recovered their normal condition, 
having lost the morbid appearances which characterized the acute 
stage, but there is still a small amount of discharge from their 
surface or from the cervical cavity, which is capable of producing 
gonorrhoea in the male. 

Gonorrhoea of the urethra usually coexists with that of the vulva, 
or vagina, and sometimes with that of the uterus alone. Cases, 
however, are reported in which this was the only part of the genital 
organs affected. Gibert met with three such instances j 1 Eicord with 
two, 2 and Cullerier with one ; 3 and in several of them, it was noticed 
that the stains of the discharge upon the woman's linen were small 
and circular, instead of being large and irregular as in cases of vul- 
var and vaginal gonorrhoea. 

The shortness of the urethra in women and the oblique position 
of the canal, which favors the spontaneous flow of matter, render the 
diagnosis of urethritis less easy than in the male. The discharge 
in cases of vulvitis, also, being seen, as might easily happen, in the 
vicinity of the meatus, may be erroneously supposed to come from 
that orifice. Again, the passage of urine causes all traces of ure- 
thritis to disappear for a time. An examination, in order to be 
conclusive, should be made at least an hour or two after an evacua- 
tion of the bladder, and any discharge around the meatus should 
first be removed. The finger may then be passed into the vagina, 
and pressure be made against the pubic arch, in the course of the 
canal, from behind forwards; when, if urethritis be present, one or 
more drops of purulent matter will appear at the meatus, the lips 

1 Gtbert's first case was published in the Revue Medicale, t. i. 1834. He hag 
also given two other cases in his Manuel sur les Maladies Syphilitiques, p. 284. 

2 Memoires de l'Academie Royale de Med., t. 2e, p. 159. Paris, 1833. 

3 Dictionnaire de Med. et de Chir. prat., t. 4e, p. 253. 



GONOEKHCEA OF THE UKETHKA — COMPLICATIONS. 161 

of which, will be found swollen and inflamed ; and the introduction 
of a sound into the canal is attended with considerable pain. Scald- 
ing during micturition may easily be a deceptive symptom, since it 
may be produced to a still greater degree by the contact of the urine 
with the excoriated mucous membrane of the vulva, when the latter 
is involved. If no vulvitis be present, it is a symptom of value. 
Gonorrhoea of the urethra, occurring in women otherwise healthy, 
does not show the same tendency to run into a gleet as in men. It 
almost always disappears before the accompanying vaginitis or vul- 
vitis, and is therefore to be regarded as of secondary importance. 1 
In broken-down constitutions, however, and in women who have 
borne many children, or who are suffering from congestion of the 
abdominal viscera, it may assume a chronic form, and prove exceed- 
ingly obstinate. A thickening takes place throughout the whole 
canal, which can be traced as a firm cord behind the pubis, and may 
be seen standing out in relief at the upper part of the entrance of 
the vulva, when the nymphae are separated. This condition is 
attended with uncomfortable sensations in the part, and a frequent 
desire to pass water, aggravated by motion, by coitus and the return 
of the menstrual period, and relieved by rest and the recumbent 
posture. 2 

The value of urethritis as indicating contagion has been noticed 
by many authors. In the majority of cases in which it is present, 
patients acknowledge that they have been exposed to impure inter- 
course. On the other hand, urethritis is absent in many cases in 
which the disease undoubtedly originated in contagion, and the 
fact is well established that it may depend upon uterine displace- 
ments and other causes independent of coitus ; hence it cannot be 
said to furnish more than presumptive proof that a woman has been 
unchaste. 

Complications. — Bubo is a less frequent complication of gonor- 
rhoea in women than in men, and Eicord states that it very rarely 
occurs unless the urethra is affected. 3 Durand Fardel reports the case 
of a woman who had a rape committed upon her by several men, 
and in whom a bubo formed and terminated in suppuration. 4 An 

1 Dueani> Fardel, Memoire sur la Blennorrhagie chez la Femme, et ses Diverses 
Complications. Journal des Connaissances Medico-Chirurg., Juillet, Aout, et Sep- 
tembre, 1840. 

2 West, Lectures on the Diseases of Women, 2d ed. p. 618. 

3 Notes to Hunter, 2d ed. p. 106. 4 Op. cit. 

11 



162 GONORRHOEA IN WOMEN. 

examination showed that she had acute inflammation of the vulva 
and vagina, and that there was no laceration or ulceration of the 
mucous membrane, yet the violent origin of the disease would excite 
suspicion as to the bubo being due entirely to the gonorrhoea. No 
mention is made of the condition of the urethra. 

Vegetations, mucous patches or tubercles, and chancres, are fre- 
quently found to coexist with gonorrhoea of different portions of 
the female genital organs, and especially with vulvitis. Their 
presence is a constant source of irritation, and their removal is 
essential to a cure of the primary disease. Vegetations should be 
destroyed by the knife or caustics ; mucous patches are a symptom 
of constitutional syphilis and require general as well as local treat- 
ment ; and chancres are to be treated according to rules to be laid 
down hereafter. 

As a general rule, gonorrhoea in women is confined to the exter- 
nal organs of generation, or does not extend above the cavity of the 
cervix, but cases are sometimes met with in which the internal sur- 
face of the body of the uterus is involved, or in which there is true 
metritis. In exceptional instances, also, the inflammation may ex- 
tend to the Fallopian tubes, and even through the continuity of 
tissue, to the peritoneum. At the post-mortem examination of a 
case of this character, M. Mercier 1 found one of the Fallopian tubes 
obliterated by a deposit of lymph upon its fimbriated extremity 
and the peritoneal surface inflamed to a considerable extent around 
it. West mentions two successive attacks of vaginitis, at an interval 
of eighteen months in the same patient, which were followed by 
such severe peritonitis as to call on each occasion for the abstraction 
of blood. 2 

Inflammation of the ovaries as a complication has also been seen 
by several authors, and has been compared to the swelled testicle 
which occurs in the male. The symptoms are well described in a 
case related by Eicord. The patient, aged thirty-two, an inmate of 
the Hopital du Midi, was suffering from acute gonorrhoea of the 
uterus and external genital organs, when a swelling suddenly ap- 
peared in the left iliac fossa. The part was very sensitive to the 
touch and its temperature increased. There was considerable febrile 
excitement and nausea. The patient lay on her back, inclined a 

' Memoire surla Peritonite consideree comme Cause de Sterilite chezles Femmes ; 
Gaz. Med., 1838, p. 577; also Gaz. des Hop , 1846, p. 432. 
1 Op. cit., p. 627. 






DIAGNOSIS. 163 



little to the left, with the thighs flexed. The discharge from the 
urethra and vagina had almost entirely disappeared. Pressure 
upon the neck of the uterus, with the finger introduced within the 
vagina, was not painful ; but when the womb was pressed toward 
the right side, pain and a sense of tension were felt in the left broad 
ligament. Pressure toward the left side, tried for the sake of com- 
parison, caused scarcely any inconvenience. The passage of the 
feces and urine, and all motion of the abdominal walls were painful. 
Under the use of antiphlogistic remedies, these symptoms gradually 
diminished and disappeared in about twelve days, and at the same 
time the discharge increased in quantity. The patient, however, 
was shortly afterwards seized with a second attack on the opposite 
side, with the same symptoms and the same suspension of the dis- 
charge. 1 

My friend Dr. Geo. T. Elliot, Jr., of this city, informs me that 
he has met with two cases of pelvic cellulitis, originating in gonor- 
rhoea. So far as I am aware, this dangerous affection has never 
before been noticed as a complication of gonorrhoea in women. 
The statement of so accurate an observer as Dr. Elliot is entitled 
to great weight, but it is to be regretted that notes of the cases, 
essential to render them conclusive as evidence of the fact stated, 
were not taken. 

Diagnosis. — Before the application of the speculum to the study 
of venereal diseases, the diagnosis of gonorrhoea in women was often 
difficult and sometimes impossible; and the discharges of vaginitis 
and of various syphilitic lesions within the vulva were confounded 
together. To a surgeon of the present day; acquainted with modern 
methods of investigation, such mistakes are not likely to occur. 
With the recognition of the disease, however, our power, so far as 
diagnosis is concerned, ceases. It is impossible to go farther and 
determine its origin. Many authors have attempted to give diag- 
nostic signs as between gonorrhoea originating in contagion and that 
produced by other causes, but they have all most signally failed to 
produce any which are at all satisfactory, simply for the reason that 
none such exist. " The microscope fails to furnish us with a means 
of distinguishing between gonorrhoeal and simple vaginitis, and no 
symptom or combination of symptoms is absolutely conclusive on 

J Notes to Hunter, p. 107. 



164 GONORRHOEA IN WOMEN. 

this point." 1 Acute inflammation and the presence of urethritis may 
render impure intercourse probable, but cannot be regarded as 
decisive; and what is wanting in the physical diagnosis must be 
sought for in the history of the case. 

Treatment. — The treatment of the different forms of gonorrhoea 
in women varies but little in the acute stage of the disease. It is 
chiefly during the chronic stage that any variation is required to 
meet special indications; presented by inflammation of particular 
portions of the mucous membrane. Moreover, nature does not 
always, nor indeed in most instances, follow the classification which 
we have found it convenient to adopt ; several of the genito-urinary 
organs are generally involved together — more commonly the vagina 
and vulva — and the treatment of this most numerous class of cases 
will first claim our attention. 

The chief remedies adapted to the acute stage are rest, cathartics, 
hot baths, lotions, and a general antiphlogistic regimen. It is of the 
first importance that the patient should abstain from exercise of all 
kinds, and, if possible, be confined to her bed ; indeed, in most cases 
her own sensations demand this, without the order of the surgeon. 
Meats and stimulants should be forbidden, and the diet restricted to 
weak tea, toast, a decoction of flaxseed, rice or barley-water, gruel, 
etc., unless the symptoms are subacute from the first, or the patient 
debilitated. In selecting a cathartic at the outset of the disease, 
preference should be given to a mercurial, for the purpose of un- 
loading the abdominal and pelvic vessels, and the bowels should 
afterwards be freely opened every day, by small doses of Epsom 
salts, citrate of magnesia or other salines. Aloes, and the numerous 
preparations which contain it, should be avoided, on account of its 
tendency to produce congestion of the hemorrhoidal vessels. 

Leeches. — The local abstraction of blood is not generally neces- 
sary, except in decidedly acute cases, when from six to ten leeches 
may be applied in the neighborhood of the vulva. There is one 
serious objection to their use, however. We can never be certain — 
except after an examination with a speculum, which the sensibility 
of the parts in this stage does not permit — that there is not a 
chancroid concealed within the vulva, the secretion of which may 
inoculate the leech-bites, and give rise to troublesome sores. Hence 

1 West, op. cit., p. 628. 



TREATMENT. 165 

if leeches be employed, they should be applied to the upper part of 
the groins or hypogastric region, where the discharge is not likely 
to reach, and their bites should be protected by an application of 
collodion or by cauterization with nitrate of silver. 1 

Batlis and Lotions. — A hot bath, repeated once or twice a day 
during the acute stage, is very grateful to the feelings of the patient, 
and beneficial in equalizing the circulation and relieving the local 
inflammation; and immersion of the whole body is to be preferred 
to hip-baths. 

Meanwhile, the external genital organs should be frequently bathed 
with some emollient lotion, and a piece of lint soaked in the same 
be inserted between the labia, in order to separate the inflamed sur- 
faces and absorb the discharge. The following is an excellent for- 
mula for this purpose : — 

R:. Decocti papaveris 3 pts. 

Liquoris plumbi subacetat. dilut. 1 pt. 
M. 

Sedatives, of which Dover's powder is perhaps the best, should 
be administered at night to induce sleep, and also at intervals during 
the day, if the pain is severe, or the patient nervous and irritable. 

The above measures are the only ones admissible during the acute 
stage of the disease, especially if the vulva is involved ; in which 
case the insertion of an enema tube is too painful to admit of injec- 
tions. When, however, the inflammation is chiefly confined to the 
vagina, the lotion just mentioned may be injected into this canal 
every few hours, and in many cases of a subacute type, injections 
may be used from the very commencement. As soon as the sensi- 
bility of the parts will permit, it is also desirable to introduce a 
speculum, and ascertain if any chancre be present. 

The kind of syringe used, and the mode of injecting, are matters 
of no little importance. The small metallic or glass instruments in 
common use are entirely inadequate for the removal of the discharge. 
The astringent ingredients of the first portion of fluid injected are 
spent in coagulating the purulent matter collected in the vagina. 
To wash away the coagula thus formed, and exert a medicinal effect 
upon the mucous membrane, the quantity of the injection should 
not be less than a pint. A pump syringe, or better still, one of 
Davidson's or Mattson's syringes, made of India rubber and pro- 

i Ricord, Legons Cliniques, Gaz. des Hopitaux, 1846, p. 157. 



166 GONORRHEA IN WOMEN. 

vided with metallic valves, will enable the patient to inject any 
desired quantity with one introduction of the tube. While using 
the injection, the patient should lie on her back, with the pelvis 
elevated ; if she merely stoop down, the fluid escapes as fast as it is 
injected, and fails to reach the deeper portions of the canal. By 
means of a bed-pan the wetting of the floor and clothes may be 
avoided. 

As a general rule, injections of greater strength may be used for 
women than for men, and for the sake of cheapness and convenience, 
they are commonly made more simple in their composition. The 
patient may be supplied with the solid ingredients, and allowed to 
mix them as required, and in order to avoid the expense of having 
them put up by the druggist in divided portions ready for use, it 
is desirable, among the poor, to supply them in bulk. A little 
instruction from the surgeon will enable the patient to measure them 
out with sufficient accuracy. A heaping teaspoonful, or, in other 
words, as much as can possibly be taken up by a teaspoon, of the 
more common ingredients of injections, is nearly as follows : — 

Alum 3ij. 

Sulphate of zinc gij. 
Acetate of zinc 5i ss « 
Subacetate of lead 5"j' 
Tannin 3;ss. 

From one to two drachms of either of these salts to the pint of 
water, is the average strength employed, but the ratio should always 
be proportioned to the effect produced, and the sensibility of the 
parts. Whenever severe or long-continued pain is induced, the 
strength of the solution should be at once diminished, and after- 
wards increased, as the tenderness becomes less. I would repeat 
what I have said with reference to injections for men, that young 
practitioners often lose time, to the neglect of more important mat- 
ters, in frequently changing from one form to another ; cases, how- 
ever, occur, in which one injection appears to lose its effect, and 
another may be substituted with advantage, but no change should 
be made, unless it is evident that the unsatisfactory result is not 
due to a faulty method of using the syringe, or to constitutional 
causes, or again, unless the solution, however diluted, excites severe 
pain and uneasiness. 

When the subsidence of the more acute symptoms first permits 
the introduction of an enema tube, a drachm of alum may be dis- 



TREATMENT. 167 

solved in a pint of flaxseed tea, and injected warm, but the temper- 
ature should be gradually lowered, and the injection ultimately 
used cold. Injections of cold water alone, during the chronic stage 
of vaginitis, are of great value. They not only cleanse the parts, 
but exert a tonic influence upon the vagina and neighboring organs. 
Their effect, however, is increased by the addition of alum, or the 
other salts above mentioned. They should be employed from two 
to three times a day, but must be omitted, for obvious reasons, dur- 
ing the menstrual periods. 

A combination of tannin and alum, as recommended by Dr. 
Tyler Smith 1 is also an excellent form of injection, and one which 
I have prescribed with much success. The proportions are 3ss-j of 
tannin, and 3ij of alum to the pint of water. Tannate of alumina 
is formed by chemical decomposition. It should be recollected, 
however, that tannin, and the salts which contain it, stain the linen 
almost as indelibly as nitrate of silver, which is a serious objec- 
tion with many women to its use. I have also employed injections 
of the sulphate and acetate of zinc, and subacetate of lead, with 
satisfactory results. Labarraque's solution of chlorinated soda, 
diluted with from eight to twelve parts of water, may be injected, 
when the discharge is very offensive. A solution of chloride of 
zinc, of the strength of from one to three grains to the ounce of 
water, is a favorite injection with some surgeons. My opinion of 
this preparation of zinc has been expressed in the chapter upon 
urethral gonorrhoea in the male. 2 

The following formula, intended as a substitute for the aromatic 
wine of the French Pharmacopoeia, is one of the best injections for 
general use : — 

R. Claret wine, 

Compound spirits of lavender, aa 3 V. 

Tincture of opium ^ss. 

Water §iijss. 

Tannin 3J— gj. 
M. 

I usually direct the patient to add two tablespoonfuls of this 
mixture to a tumblerful of water, and to gradually increase the 
strength. 

I rarely prescribe a solution of nitrate of silver for the patient's 

1 Pathology and Treatment of Leucorrhoea, p. 183. 

2 See p. 69. 



168 GONORRHOEA IN WOMEN". 

own employment, but frequently myself apply it to the vaginal 
walls, by first introducing a glass speculum as far as the cervix 
uteri, and then pouring a few drachms through the instrument. If 
the speculum be slowly withdrawn, the fluid will come in contact 
with the whole extent of the vagina. I regard this method as one 
of special value, for if the patient lie on her back with the pelvis 
well elevated, and if the speculum be as large as the parts will 
admit, the force of gravity carries the solution into every, recess of 
the dilated vagina, and insures its thorough application to this canal, 
and also, in a measure, to the cavity of the cervix. The parts 
should be thoroughly cleansed with copious injections of simple 
water, before the speculum is introduced. In this manner, a solu- 
tion of nitrate of silver, containing 9j-iij to the ounce, may be ap- 
plied by the surgeon every third or fourth day, and the patient at 
the same time use some mild astringent injection twice a day. 

An application of the solid nitrate of silver crayon, a favorite 
method of treatment among French surgeons, is requisite in some 
cases which do not improve under a solution of the same salt. The 
deepest folds of the vagina should be exposed by means of a bivalve 
speculum, and the caustic applied to the mucous membrane cover- 
ing the cervix, and to that of the vaginal walls, as they are brought 
into view by the gradual withdrawal of the instrument. The com- 
pound tincture of iodine, pencilled over the surface, with a camel's- 
hair brush attached to a long handle, is sometimes preferable to the 
lunar caustic. 

The contact of purulent matter with the mucous membrane of 
the genital organs is doubtless a constant source of irritation, and is 
probably sufficient to account for some of the superficial abrasions 
and other lesions, revealed by a specular examination. The col- 
lection and retention of pus upon the external integument will soon 
excoriate the surface, and, with still greater reason, may it be sup- 
posed to act thus upon the more delicate mucous membrane. The 
abrasions, once formed, increase the quantity of the discharge by 
their own secretion, and thus the two react upon each other, and 
prolong the disease. This evil is easily remedied in balanitis and 
vulvitis by interposing between the inflamed surfaces some porous 
material, capable of absorbing the discharge as fast as it is secreted, 
and wet, if desired, with an astringent lotion, which will exert a 
constant medicinal effect upon the mucous membrane. The same 
result may be attained in vaginitis, and has even been attempted in 



TREATMENT. 169 

gonorrhoea of the cervix. 1 For this purpose, a folded piece of lint 
is sometimes used, but a plumasseau of charpie or carded cotton is 
preferable, since it retains its elasticity to a greater degree, and is 
a better absorbent. To facilitate its withdrawal, a small string may 
be previously attached to it. The size of this tampon must be pro- 
portioned to the dimensions of the vagina in each case, and will 
vary in diameter from half an inch to two inches. In some in- 
stances, it is medicated ; in others, not. In the former case, the 
medicinal substance may be an absorbent or astringent powder, as 
prepared chalk, subnitrate of bismuth, calamine, tannin, powdered 
alum, etc. ; or, it may consist of any of the lotions which have been 
recommended for the purposes of injections either in the male or 
female. Calamine and powdered alum are the best dry prepara- 
tions, and a solution of tannin in glycerin (5j-ij ad <fj) an excellent 
fluid astringent. The plug may be inserted by the surgeon through 
a speculum, or the patient may be taught to introduce it with her 
finger, or by means of a stylet. It should be withdrawn at the end 
of twelve hours, the vagina washed out with a copious injection, 
and a fresh plug introduced, or the latter may be deferred till the 
following day. 

Scanzoni employs a plug of cotton wool, sprinkled with alum 
powder, either pure or mixed with one or two parts of sugar. Pure 
alum is liable, on the second or third application, to excite a very 
disagreeable sensation of heat and constriction in the vagina, render- 
ing it necessary to suspend the treatment for a week or two ; hence 
it is not to be used undiluted, unless the parts are quite insensible ; 
and on this account, therefore, it will be best to try, in the majority 
of cases, a mixture of alum and sugar. The plug, thus prepared, 
should not be used oftener than every second or third day, nor be 
allowed to remain in longer than twelve hours, and warm water 
should be injected immediately on its withdrawal. If these pre- 
cautions be neglected, acute inflammation of a troublesome character 
may be excited, and the discharge augmented instead of diminished. 2 

Demarquay recommends a plug moistened with a solution of one 
part of tannin in four parts of glycerin. His directions are : first to 
subdue the inflammatory symptoms of the acute stage by appro- 

1 Hourmann, Du Taraponnement, comme Methode de Traitement des Ecoule- 
ments Utero-vaginaux. Journal des Connaissances Medico-Chirurg., Mars, 1841, 
p. 89. 

2 Op. cit., p. 456. 



170 GONORRHCEA IN" WOMEN. 

priate regimen, baths and frequent emollient injections; next as 
soon as a speculum can be introduced, to inject simple water in 
large quantities, so as to remove all secretion from the vaginal 
walls, which are afterwards to be dried bj means of swabs; and, 
finally, to introduce plugs of charpie saturated with the mixture of 
tannin and glycerin. On the following day, the patient should take 
a bath, the plugs be removed, the injections repeated, and fresh 
plugs introduced. M. Demarquay states that he has never found it 
necessary to renew these applications more than four or five times. 
After discontinuing them, astringent injections, consisting of an in- 
fusion of walnut leaves, in which one drachm of alum to the quart 
has been dissolved, should be used two or three times a day for a 
week or ten days. 1 The active principle of the infusion of walnut 
leaves, recommended by M. Demarquay, is tannin, and a convenient 
substitute may be found in a solution of alum and this vegetable 
acid in simple water, according to the formula previously given. 

Thiry exposes the vaginal walls with a speculum ; cauterizes the 
surface, if much inflamed, with solid nitrate of silver ; then sprinkles 
over it finely powdered charcoal or cinchona, and introduces a tam- 
pon of cotton wool, which he allows to remain from three to five 
hours. 2 

Simpson, of Edinburgh, has proposed an efficacious mode of 
keeping an astringent in constant contact with the vaginal walls, 
by means of pessaries, prepared according to the following formu- 
las:— 

R:. Acidi taimici J^ij. 

Cerse albse "$v. 

Axungise 5 V J« 
Misce, et divide in Pessos quatuor. 

R^. Aluminis gj. 

Pulveris catechu gj. 

Cerse flavse 3J. 

Axungise £vss. 
Misce, et divide in Pessos quatuor. 3 

Hip-baths, taken every morning on rising or in the early part of 
the day, are valuable adjuvants in the treatment of chronic vaginitis. 
The temperature of the bath should be determined in part by the 
season of the year, and in part by the strength and habits of the 

1 Bulletin de Therapeutique, tome i. p. 541. 

2 Journal de Med. de Bruxelles, Fev. 1854. 

3 Edinburgh Monthly Journal, June, 1848, and Obstetric Works, p. 98. 



TREATMENT. 171 

patient. It is well to commence with lukewarm water, and gradu- 
ally lower the temperature as the system becomes accustomed to 
them ; but they should never be so cold nor continued so long, that 
the patient feels chilly for some time after their employment, and 
reaction should be promoted by friction with a coarse towel, flesh- 
brush or hair-mitten. These baths may be rendered still more 
effectual by the addition of a handful of coarse salt to each bucket 
of water used. Astringents, as alum, in the proportion of half a 
pound to each bath, are also recommended by some authors. 

The hygienic management of the case should always receive special 
attention in chronic vaginitis. As the inflammatory symptoms of 
the acute stage subside, the patient may be allowed a more generous 
diet and greater freedom of motion, but she should still avoid violent 
or prolonged exercise, and especially all sexual excitement. Walk- 
ing and even standing for any length of time should be but moder- 
ately practised at this stage of the affection. No absolute rules can 
be laid down for diet, which should be adapted to each individual 
case. In general, the food should be plain and simple, and yet 
sufficiently nourishing, and the meals should be taken at regular 
hours. Highly seasoned dishes, pastry, salt meats, cheese and strong 
tea and coffee, should be forbidden ; and bread, eggs, fresh meat 
once a day, vegetables, and simple puddings, recommended. Eegu- 
larity of the bowels should be secured, if necessary, by small doses 
of saline cathartics, taken on rising in the morning; and, in brief, 
all such measures should be adopted, as are calculated to bring the 
general health to the best possible condition. The latter rule implies 
that the system should neither be stimulated above, nor depressed 
below, the happy mean; yet, at the same time, there are but few 
cases of chronic vaginitis which do not require some support, and 
in which either mineral acids, preparations of iron, vegetable tonics, 
quinine, or even stimulants, are not, at some period, indicated. 
There is really no inconsistency in pulling down with one hand, 
and, at the same time, building up with the other; in applying 
leeches, for instance, to the cervix, and unloading the pelvic vessels 
by cathartics, while tonics are given to elevate the general tone of 
the system. Such a course must often be pursued, especially with 
corpulent women of sedentary habits, whose condition, in spite of 
their apparent excess of health, is in reality below par. I would 
refer the reader to the chapter on gleet, for much that has reference 
to the hygienic management of chronic vaginitis, which is in fact 



172 GONORRHOEA IN WOMEN*. 

the analogue of gleet in man. In both, of these affections, constitu- 
tional and local treatment must proceed hand in hand, if any perma- 
nently good result is to be attained. 

The formulae for various tonics, already given when treating of 
this disease in the male sex, are equally applicable to the female. 
The only one which I would add at present is the following old, but 
excellent combination of a tonic, cathartic, and astringent. Its 
cheapness recommends it especially for the poorer class of patients, 
while for those in better circumstances a more palatable substitute 
may be found in Seidlitz powders or citrate of magnesia, taken on 
rising from bed, and in the French dragees of iron administered just 
before or after meals. 

E:. Magnesise sulphatis §iss. 

Ferri sulphatis 9ij. 

Acidi sulphurici gtt. x. 

Infusionis gentianse comp. Oj. 
M. 
A tablespoonful two or three times a day. 

In gonorrhoea of the 'vulva lotions may be applied with great facil- 
ity, and the parts separated by the interposition of lint or charpie. 
Cauterization with the solid nitrate of silver or a solution of this 
salt is often beneficial. Eesolution of a commencing abscess of the 
vulvo-vaginal gland or duct may sometimes be obtained by rest, 
cathartics, and antiphlogistic regimen, assisted, in some cases, by the 
application of leeches to some adjacent part. If suppuration takes 
place, the abscess should be opened without delay. Eicord and 
Yidal advise making the incision upon the external surface of the 
labium, to avoid the admission of the urine and discharges, which 
would irritate the cavity of the abscess and prevent its healing. 
An incision in this situation, however, fails to prevent a spontaneous 
opening on the mucous surface, where the abscess naturally tends 
to point. 1 By making a small incision on the internal and inferior 
aspect of the tumor, and directing the knife somewhat upwards so 
that the cut shall be valvular, and also by allowing the abscess to 
evacuate itself by the contraction of its walls without the exercise 
of pressure, the entrance of foreign matter may generally be pre- 
vented. In case the abscess repeatedly recurs, its exact seat should 
be carefully ascertained. If it occupy the duct, it should be laid 
open by a free incision, and the cavity filled up with lint. If it be 

1 Huguier, op. cit., p. 843. 



TKEATMENT. 173 

seated in the gland, this must be dissected out. I have tried, in 
several instances, to cure these abscesses by the introduction of a 
seton, but have always failed. 

Whenever, after an attack of vulvitis, there still remains a puru- 
lent discharge from the vulvo-vaginal duct, and also in the cases 
described by Dr. Salmon in which this part is primarily affected, a 
solution of nitrate of silver may be injected by means of Anel's 
syringe. 

In gonorrhoea of the uterus, the cervical cavity should first be thor- 
oughly cleansed of its muco-purulent secretion by means of swabs 
of cotton wool introduced through the speculum, and its internal 
surface then cauterized with a stick of nitrate of silver, which should 
be passed as high up as possible. To avoid breaking the nitrate 
within the uterus — an accident attended by no very serious conse- 
quences, however — crayons of this salt may be obtained, diluted 
with nitrate of potash or chloride of silver, which adds greatly to 
its firmness without materially diminishing its remedial power. 
This application should be repeated every third or fourth day, and 
the astringent injections, which are continued in the intervals, should 
be made to reach as high as the cervix. In obstinate cases, the 
saturated tincture of iodine, crayons of potassa cum calce, or the 
acid nitrate of mercury may be applied to the cervical cavity in a 
similar manner ; but when the stronger caustics are used, care should 
be taken to guard the upper portion of the vagina from injury. 

Intra-uterine injections have been recommended in the treatment 
of gonorrhoea of the cervix, especially by Vidal de Cassis; 1 but in 
several instances severe and even fatal peritonitis has been produced, 
probably in consequence of the fluid reaching the abdominal cavity 
through the Fallopian tubes. This has been shown to be possible 
by experiments upon the dead body, performed by Bretonneau, 
Hourmann, d' Astros, and others. It appears from some of their 
observations, that the injected fluid may even gain entrance to the 
venous system. 2 This practice is therefore generally abandoned at 
the present day. 

Whenever, in gonorrhoea of the vagina or uterus, the cervix is 
found enlarged and congested, from four to six leeches may be 

1 Essai sur le Traitement de quelques Mai. de l'Uterus, Injections Intra-vaginales 
et Intra-uterines. Paris, 1840, in-8. 

2 Hourmann, Note sur le Danger des Injections faites dans l'Uterus. Journal 
des Connaissances Med.-Chirurg., July, 1840, p. 22. 



174 GONORRHOEA IN WOMEN. 

applied. They are especially applicable at the outset of the treat- 
ment, and may require to be repeated once or twice at intervals of 
a week ; but the patient should not be debilitated by their frequent 
use. The surgeon should apply them himself, taking care to plug 
the cervix beforehand, that they may not fasten upon the sensitive 
membrane of its internal surface. If the flow of blood is excessive 
it may be arrested by cold injections of a solution of alum. 

The acute stage of urethritis is of so short duration as to demand 
but little special treatment. In most cases, the measures adopted 
for the concomitant inflammation of the vulva, vagina, or uterus, 
aided, perhaps, by the administration of alkalies, neutral salts, or 
sedatives, are sufficient to effect a decided amelioration, and often 
the entire disappearance of the disease. When this result fails to 
be attained, I do not hesitate to resort to injections, as in urethral 
gonorrhoea in men ; but as they cannot be used by the patient, it is 
necessary for the surgeon to administer them himself. Their active 
principle may be one of the salts of lead or zinc, or tannin ; or from 
one to two drachms of a solution of nitrate of silver, containing ten 
or twenty grains to the ounce, may be thrown in. If, in this case, 
we carefully guard against having the bladder entirely empty, no 
evil result need be feared. 

Copaiba and cubebs may also be employed in this affection, ad- 
ministered in the manner directed for men. 1 Kicord's experiments 
have shown that their effect in gonorrhoea of any portion of the 
genital organs not traversed by the urine is so slight, that they are 
not to be recommended in vaginitis or vulvitis. Indeed, they can 
readily be dispensed with in all forms of gonorrhoea in women. 

1 See p. 74. 






GONORRHCEAL OPHTHALMIA. 175 



CHAPTER X. 

GONORRHEAL OPHTHALMIA. 

Gonorrhceal ophthalmia lias been supposed to originate in 
three ways — from inoculation, from metastasis, and from sympathy, 
each of which has from time to time been received by certain 
authors as its exclusive mode of origin. 

The occurrence of gonorrhceal ophthalmia from inoculation or 
contagion, cannot, at the present day, be called in question. Nu- 
merous cases reported by Mackenzie, by Lawrence, and by nearly 
every modern writer on diseases of the eye, leave no room to doubt 
that the discharge of gonorrhoea applied to the ocular conjunctiva, 
may set up a severe and destructive form of inflammation, similar 
to if not identical with purulent conjunctivitis. But, besides these 
reports of cases in which the inoculation has been the result of 
accident, farther proof is to be found in the treatment of pannus — ■ 
employed of late years chiefly by French and German surgeons — 
in which the eyes have been intentionally inoculated with the pus 
of gonorrhoea. Discharges from the genital organs have been 
transferred to eyes affected with pannus, with the express design of 
exciting acute inflammation, which, it was hoped, might cure the 
chronic disease ; and, however questionable may have been the 
results of this practice, so far as the accomplishment of the latter 
purpose is concerned, there has been, at all events, no difficulty in 
producing acute inflammation by such inoculation. With these 
facts before us, therefore, no farther doubt of gonorrhceal ophthalmia 
from contagion is admissible ; indeed, direct inoculation is now 
regarded by all surgeons, with but few exceptions, as the only 
mode in which originates that destructive form of purulent con- 
junctivitis which sometimes attends gonorrhoea. 

The idea of a metastatic origin of gonorrhceal ophthalmia was 
first advanced by Saint Yves, who was acquainted with no other 



176 GONOKRHCEAL OPHTHALMIA. 

mode, as appears from his chapter, " Of the Venereal Ophthalmy," 1 
which is so short, quaint, and interesting, that I shall quote it in 
extenso: "This tenth species of ophthalmy has almost the same 
signs with the precedent ('the most dangerous ophthalmy, called 
chemosis'), with this difference that the conjunctiva, which is 
swelled, appears hard and fleshy. It begins thus : a great quantity 
of whitish matter with a yellowish cast, oozes constantly through 
the eye. This disease, which proceeds from a venereal- cause, is 
very rare ; yet I have seen several attacked with it. In most of 
them, this disease appeared two days after the beginning of a viru- 
lent gonorrhoea ; the matter, not running off by its usual passages 
was removed to the eye, through which there flowed a like matter, 
which stained the linen in the same manner as when it passed 
through the usual channels." 

Gonorrhoeal ophthalmia from metastasis, as here stated, implies a 
translation of the disease from the genital organs to the eye ; and, 
to prove its existence, it would be necessary to produce unques- 
tionable instances in which the urethral discharge has suddenly 
subsided or disappeared prior to the inflammation of the ocular 
tunics. But few cases, however, at all likely to fulfil these con- 
ditions, have been adduced, and even these few have been of such 
doubtful character, that the idea of a metastatic origin of gonor- 
rhoeal ophthalmia is at the present day almost entirely abandoned. 

Still, numerous instances are on record of disease of the eye 
accompanying gonorrhoea, in which the circumstances of the case 
preclude the admission of direct inoculation, and in which the 
symptoms and course of the ophthalmia are decidedly different 
from those of gonorrhoeal ophthalmia from contagion. While dis- 
carding the term metastatic as applied to these cases, many surgeons 
have given them the name of sympathetic ; rather as a convenient 
expression, however, than as really explaining their mode of origin. 
In the next chapter I shall endeavor to show that all those cases 
which have been termed metastatic a«ud sympathetic gonorrhoeal 
ophthalmia, are merely a manifestation of gonorrhoeal rheumatism, 
which, like ordinary rheumatism, may attack several of the ocular 
tissues. At present, I shall consider gonorrhoeal ophthalmia origi- 
nating in contagion, and allied to purulent conjunctivitis. 

1 A New Treatise of the Diseases of the Eyes, by M. De St. Yves, Surgeon Oculist 
of the Company of Paris, translated from the original French by J. Stockton, M. D., 
London, 1741, p. 168. 



FREQUENCY— CAUSES. 177 

Frequency. — Next in order to swelled testicle, gonorrhoeal 
ophthalmia is the most common complication of gonorrhoea ; and 
yet, considering the great frequency of the latter disease, which 
everywhere abounds, it is comparatively a rare affection. The 
following table exhibits the number of cases of gonorrhoeal oph- 
thalmia received at the 1ST. Y. Eye Infirmary during a period of 
fifteen consecutive years, and the proportion which these cases bear 
to the whole number of patients. 

Whole Number Cases of Gonorrheal 
Year. of Patients. Ophthalmia. 

1845 1366 2 

1846 1245 3 

1847 ....... 1485 2 

1848 1815 5 

1849 1902 3 

1850 2082 3 

1851 . ■ 2472 6 

1852 2732 7 

1853 2719 5 

1854 2635 6 

1855 . 2652 5 

1856 ....... 2634 4 

1857 3216 3 

1858 3908 2 

1859 4171 3 

Total 37,034 59 

It thus appears that, compared with the whole number of dis- 
eases of the eye treated at this institution, cases of gonorrhoeal 
ophthalmia are only as I to 628. We have no statistics by which 
to determine the proportion of this disease to the whole number of 
cases of gonorrhoea ; yet I think the experience of every physician 
would lead him to infer that it is not much greater than to diseases 
of the eye, since gonorrhoea must be nearly as frequent as all ocular 
affections combined. 

Causes. — The contagious matter which has produced acute in- 
flammation of the conjunctiva in a given case, may have been 
derived from the genital organs or from the opposite eye — already 
affected with gonorrhoeal ophthalmia — of the same, or from those 
of another person. An opinion, originating with Mr. Vetch, 1 pre- 
vailed at one time, that the pus of gonorrhoea was innocuous when 

1 A Practical Treatise on the Diseases of the Eye. London, 1820. 
12 



178 GONORRHEAL OPHTHALMIA. 

applied to the eye of the individual secreting it. This surgeon 
drew this conclusion from several unsuccessful attempts which he 
made to inoculate the urethras of persons suffering from gonorrhoeal 
ophthalmia with their conjunctival discharge, in the hope of " divert- 
ing the disease from the eye to the urethra." At the same time he 
succeeded in producing urethritis in another patient by applying 
to his meatus matter taken from the eye of another. The results 
of these experiments, however, have been proved to be worthless, 
and the fact is now well established, that the source from which the 
matter is derived does not influence its power of contagion. In 
many of the reported cases of this disease, the ophthalmia was 
produced by patients washing their eyes with their own urine, 
with which gonorrhoeal pus was mixed, or by otherwise applying 
the discharges from their own persons. 

The personal habits of those affected with gonorrhoea, and the 
degree of intimacy existing between members of the same house- 
hold, will, in a great measure, determine the frequency of infection. 
Among the poor and squalid, where cleanliness is neglected and 
the same vessels and towels are used in common, gonorrhoeal oph- 
thalmia may readily be communicated from one individual to 
another, until it has attacked all the members of the same family. 

Ricord states that he has never seen gonorrhoeal ophthalmia pro- 
duced by discharges from any portion of the genital organs except 
the urethra ; and that he has never known it to be caused by the 
pus of balanitis or vaginitis. There is reason to believe, however, 
that a simply vaginal discharge is capable of exciting the disease 
under consideration. 

It is a well established fact that " ophthalmia neonatorum" is fre- 
quently caused by inoculation of the infant's eyes with leucorrhoeal 
discharges from the mother. I have repeatedly seen severe puru- 
lent conjunctivitis in very young girls, who were affected with that 
form of vaginitis which sometimes attacks children, independently 
of contagion, and which has been so ably treated of by Mr. Wilde, 
of Dublin. Analogous cases are reported in treatises on diseases 
of the eye, and Dr. Jimgken mentions one instance, in which the 
ophthalmia, originating in this manner, spread to seven members of 
a family. 1 

I know of no authentic case of gonorrhoeal ophthalmia occasioned 

1 Annales d'Oculistique, 8 e serie, t.' ler, p. 355. 



CAUSES. 179 

by the pus of balanitis. Matter from a venereal or ordinary abscess 
must also be regarded as generally innocuous. Yet it is, perhaps, 
impossible to determine with accuracy the limits within which puru- 
lent matter is capable of exciting severe inflammation of the con- 
junctiva. The predisposition of the person exposed will doubtless 
have no small influence upon the effect produced. Still, so far as at 
present known, these limits are confined to the urethra and vagina. 

The inoculations which have been employed in the treatment of 
pannus, will throw some light upon the conditions under which con- 
tagion may be supposed to take place. The puriform matter used in 
these inoculations has been derived either from the genital organs, 
or from an eye affected with gonorrhoeal ophthalmia, or ophthalmia 
neonatorum. When such matter is kept from contact with the air, 
it is found to retain its contagious property for about sixty hours. 
If exposed to the air, and allowed to dry, it soon becomes innocu- 
ous. In the experiments of M. Piringer, of Gratz, a piece of linen 
was moistened with gonorrhoeal matter, and allowed to dry ; the 
cloth was then rubbed upon the eyes of several persons, and no 
inoculation ensued. The dried matter scraped from the cloth, and 
applied directly upon the conjunctiva, took effect within about 
thirty- six hours after it was first obtained. Matter, once dried and 
immediately moistened again, either by the addition of water or by 
contact with the secretions of the eye, was found to be contagious. 
Fresh matter was contagious, even when diluted with one hundred 
parts of water. 

M. "Van Eoosbroeck experimented with the pus of a common 
abscess, and found that it was innocuous when applied to the eye. 
This surgeon was also led to the conclusion that the discharge from 
an eye affected with purulent ophthalmia, diluted with water, retains 
its power of contagion until decomposition has begun to take place, 
as shown by its evolving the odor of putrefaction. 

When the inoculation is successful, no disagreeable sensation is 
at first excited by the application of the matter; and no effect 
is perceived until after the lapse of from six to thirty hours, 
when the eye begins to feel hot, and there is an increase in the ocu- 
lar secretions, which are at first entirely mucous, but soon become 
muco-purulent. 

Gonorrhoeal ophthalmia is much more common in men than in 
women. Ricord ascribes this difference to the greater frequency of 
urethritis in the male, this being the only form of gonorrhoea, capa- 



180 GONORRHEAL OPHTHALMIA. 

ble, as lie supposes, of occasioning gonorrhceal ophthalmia. I have 
already dissented from this opinion of Kicord, and I believe that so 
far as any explanation can be given of the difference in the relative 
frequency of its occurrence in the two sexes, it must be based upon 
their different habits. 

Symptoms. — Gonorrhceal ophthalmia may occur at any stage of 
an attack of gonorrhoea; although it is said to be more frequent 
during the decline. The urethral or vaginal discharge is doubtless 
most contagious when most purulent, which is during the acute 
stage, but the short duration of this stage affords less opportunity 
for it to be applied to the eye than the longer stage of decline. At 
first, the disease usually attacks one eye alone. It may remain con- 
fined to this eye, but not unfrequently, after the lapse of a few days, 
the opposite eye becomes implicated. 

The symptoms of gonorrhceal ophthalmia are, in the main, iden- 
tical with those of purulent conjunctivitis. The former disease, 
however, is more rapid in its development, and even more destruc- 
tive to sight than the latter. 

The earliest indications of an attack of this disease are an itching 
sensation just within or on the margins of the lids, a feeling as if 
some foreign body were in the eye, and an increase in the ocular 
secretions. The latter retain at the outset their normal transparency, 
although they appear unusually viscid ; the cilise become adherent 
and glued together, and a collection of dried mucus may be seen at 
the inner canthus. As the disease progresses, the vessels under- 
lying the conjunctiva become distended with blood. They may at 
first be distinguished from each other as in simple conjunctivitis, 
but they are soon lost in a uniform red appearance of the globe, 
extending as far as the cornea ; which retains its normal transpa- 
rency. The conjunctiva is also found to be somewhat elevated 
above the sclerotica by an effusion of serum, and its surface is 
roughened by the development of its papillae. Meanwhile, the 
discharge has become purulent, and is secreted abundantly from 
the inflamed surfaces. 

An attack of gonorrhceal ophthalmia is so rapid in its progress, 
that the early symptoms just now described may have passed away 
before the first visit of the surgeon, who is often called to see his 
patient only after the full development of the disease. He probably 
finds him sitting up, his head bent forwards, his chin resting on his 



SYMPTOMS. 181 

breast, and his handkerchief applied to the cheek to absorb the 
discharge, which irritates the snrface upon which it flows. The 
eyelids are swollen, especially the upper, which slightly overlaps 
the lower, and is of a reddish or even dusky hue. The patient states 
that he is unable to open the eye. His inability to do so is caused 
less by an intolerance of light, than by the mechanical obstruction 
which the swelling of the lids occasions, and by the pain which is 
excited by any friction of the inflamed surfaces upon each other. 

The surgeon now moistens the edges of the lids with a rag dipped 
in warm water in order to facilitate their separation, and proceeds 
with his examination. In his attempt to open the eye, he is careful 
not to make pressure upon the globe, in order to avoid giving 
unnecessary pain, and also, lest the cornea, if already ulcerated, 
may be ruptured, and the contents of the globe escape. With one 
finger placed just below the eye, he slides the integument down- 
wards over the malar bone, and thus everts the lower lid ; the upper 
lid being elevated by a similar manoeuvre with another finger of 
the same hand applied below the edge of the orbit ; or, again, he 
may expose the globe by seizing the lashes of the upper lid with 
the thumb and finger and drawing the lid forwards and upwards. 
All this may be accomplished with the left hand, the right being 
left free to wipe away the discharge, or to make applications to the 
eye. 

As soon as the lids are separated, a quantity of thick, yellow pus 
wells up between them and partially obstructs the view ; the swollen 
palpebral conjunctiva, compressed by the spasmodic action of the 
orbicularis muscle, may also project in folds. The collection of 
matter is now removed with a soft, moist sponge or rag, and the 
surface of the ocular conjunctiva exposed. This membrane is found 
to be of a uniform red color, with its vessels undistinguishable from 
each other, and elevated above the sclerotica by an effusion of 
serum and fibrin in the cellular tissue beneath it. This swelling 
of the conjunctiva is seen to terminate at the margin of a central 
depression occupying the position of the cornea, and filled with a 
collection of the less fluid constituents of the puriform discharge, 
which may at first sight be mistaken for the debris of a disorganized 
cornea. On removing this matter, however, the latter structure 
may still be found clear and transparent, at the bottom of the 
depression, where it is overlapped by the swollen conjunctiva. In 
less fortunate cases, it may have become hazy from the infiltration 



182 GONORRHEAL OPHTHALMIA. 

of pus between its layers, or ulceration may have already com- 
menced. If an ulcer is not evident on first inspection, it may often 
be discovered at the margin of the cornea by gently pushing to one 
side the overlapping fold of conjunctiva. Meanwhile, the secretion 
of pus is constantly going on and requires repeated removal. It is 
astonishing to observe how large a quantity of this fluid can be 
secreted by so limited a surface. The secretion has been estimated 
at more than three ounces per day. 

The amount of pain, occasioned by this disease, varies in different 
cases. During the development and acme of the inflammation, it is 
generally severe. It is described by the patient as a sensation of 
burning heat and tension in the eyeball, radiating to the brow and 
temple. The system at large sympathizes with the local disease. 
For a time there may be general febrile excitement, but symptoms 
of depression soon appear ; the pulse becomes rapid and irritable, 
the skin cold and clammy, and the patient anxious and nervous. 
This depression of the vital powers is not invariably met with, but 
is the most frequent condition of the patient, after the disease has 
continued for a few days; and it may occur even at an earlier 
period, when the health has been previously impaired by any cause. 

Notwithstanding the severity of the symptoms, resolution is still 
possible. Under proper care and treatment, the inflammatory action 
may abate, and the tissues recover their normal condition, leaving 
the eye as sound as before the attack. So fortunate a result, how- 
ever, is more to be hoped for than confidently anticipated. The 
chances of success are greater when the case is seen at an early 
period, before the effusion beneath the conjunctiva has been ren- 
dered firm by a deposit of fibrin, or before ulceration of the cornea 
has commenced. The latter is the chief danger to be feared. Ulcer- 
ation usually commences at the margin of the cornea, and may 
extend around its circumference, or advance towards its centre. It 
is in some cases superficial; in others, it penetrates through the 
whole thickness of the cornea, and prolapse of the iris ensues, or 
more or less of the contents of the globe escapes. Sometimes a 
portion or the whole of the corneal membrane becomes disorgan- 
ized, and comes away en masse. The eye has been known to be 
destroyed in this manner within twenty-four hours after the first 
symptoms of the disease were observed, and this catastrophe is said 
to have occurred in a single night, in a case at the New York Hos- 
pital. The escape of the aqueous humor, and other contents of the 



DIAGNOSIS— TEEATMENT. 183 

globe, is usually followed by an amelioration of the pain, and the 
patient often entertains the hope that he is improving, while the 
surgeon knows that his sight is irretrievably lost. 

The amount of permanent injury inflicted upon the eye will de- 
pend upon the extent and situation of the ulceration. When the 
latter has been superficial, and situated near the margin of the cor- 
nea, the resulting opacity will not interfere with vision, and even 
when the leucoma is central, an operation for artificial pupil is still 
practicable, if any portion of the cornea remain clear. Perforation 
of the anterior chamber and prolapse of the iris, when partial, may 
also be remedied by art ; but when the whole, or the larger portion 
of the cornea has sloughed away, and the prolapsed iris has become 
covered with a dense layer of fibrin, forming an extensive staphy- 
loma, the case is hopeless. i 

Diagnosis. — Independently of the history of the case, we have 
no means of distinguishing gonorrhceal ophthalmia from severe 
purulent conjunctivitis. It has been asserted that the former com- 
mences in inflammation of the ocular conjunctiva, while the latter 
first affects the lining membrane of the lids. Even if this were 
true, it would afford but little assistance in the diagnosis, since we 
are rarely enabled to watch the early symptoms. 

Dr. Hairion, 1 Professor of Ophthalmology at the University of 
Louvain, supposed he had discovered a diagnostic sign of gonor- 
rhceal ophthalmia in the presence of a bubo in front of the ear ; but 
as no one else ever saw such buboes in this disease, the statement 
must be regarded as a sad instance of obliquity of vision produced 
by preconceived notions as to the nature of the disease. 

Tkeatmext. — In undertaking the treatment of a case of gonor- 
rhoea! ophthalmia, it is of the first importance that the patient be 
intrusted to the care of an intelligent, careful, and faithful nurse, 
whose whole time and attention can be devoted to carrying out the 
surgeon's directions. This disease is so rapid in its progress, that 
neglect for a few hours only may prove fatal to vision ; if the eye 
be saved, a large share of the credit will be due to the faithfulness 
of the attendant. It hardly need be said that the light touch and 
gentle hand of a devoted woman should be secured, if possible. 

1 Aunales d'Oculistique, t. xv. p. 159. 



184 GONORRHEAL OPHTHALMIA. 

The directions of the surgeon should vary according to the stage 
of the disease. If the inflammation has commenced within a few 
hours only, and has not as yet attained its height, from four to six 
leeches may be applied near the external canthus of the affected eye, 
or a number of them be made to attach themselves to the mucous 
membrane of the corresponding nostril. If leeches are not at hand, 
cups to the temples will suffice. Such local depletion may generally 
be repeated with benefit, for a day or two, once or twice in the 
twenty -four hours, especially if the patient be of full habit. If, 
however, the disease progresses unchecked, and especially if there 
be any symptoms of general depression of the system, even this 
slight abstraction of blood should be avoided. It is adapted only 
to the early stage of the inflammation, and, at a later period, is use- 
less, if not positively injurious. 

A free purge should be administered, as, for example, five grains 
of calomel followed by half an ounce of castor oil, a full dose of 
Epsom salts, or three " compound cathartic pills." With regard 
to the diet of the patient, much will depend upon his general con- 
dition. As a general rule at this early stage, it should be light, 
consisting of gruel, broths, etc.; at the same time it is important to 
recollect the tendency in this disease to depression of the vital 
powers, and to be governed by the indications of each individual 
case. 

Lastly, but by no means of least importance, the directions which 
will presently be given for the frequent cleansing of the eye, should 
be insisted on, and a collyrium of nitrate of silver, ten grains to the 
ounce, should be dropped between the lids every two hours, or 
every hour in threatening cases. 

The treatment above recommended is intended for the early 
stage of gonorrhoeal ophthalmia, before much chemosis, swelling of 
the lids, or other severe symptoms have set in. In most cases, 
however, as already stated, the surgeon does not see his patient till 
the disease has attained its height, when some modification of the 
above treatment is required. 

Leeches and cups can now rarely be used to advantage. At the 
best, they will be impotent to stay the progress of the inflammation. 
Cathartics should be given as in the first stage, 1 and one or two free 

1 When the disease has already made considerable progress before the surgeon 
is called, an active cathartic, as croton oil, should be selected. 



TREATMENT. 185 

evacuations from the bowels secured each day. Here again the 
general condition of the patient will in a measure determine the 
diet to be recommended ; but in the great majority of cases nourish- 
ment should be administered as freely as the appetite will admit, 
and may consist of bread, milk, beef-tea, steaks, mutton, eggs, etc. 
When the patient is unable to eat, and especially if his skin is found 
to be cool and his pulse irritable, or again, if ulceration of the cornea 
has already commenced, we must resort to stimulants and tonics. 
These are almost always required in this stage of the disease in 
hospital practice, where patients are generally more or less cachectic, 
and even in private practice the subjects of gonorrhceal ophthalmia 
are often run down by an irregular course of life. Nothing will 
so much contribute to hasten destructive ulceration of the cornea as 
a low state of the vital powers. The least indication of this con- 
dition should be met by quinine, ale, porter, wine, or milk-punch, 
freely administered. 

The room occupied by the patient should, if possible, be spacious, 
dry, and well ventilated. The eyes may be protected from a glare 
of light by the position of the patient, or by a pasteboard shade, or 
by curtains ; but the room should not be entirely darkened, as the 
complete exclusion of light favors congestion of the eye. With 
still stronger reason, should the eyes be uncovered and kept free 
from poultices, alum-curds, tea-leaves, raw oysters, or similar appli- 
cations, which are often recommended by some officious acquaint- 
ance. No surer way of destroying the sight could be devised than 
by using these articles. 

When chemosis has already taken place, no time should be lost 
in dividing the conjunctiva and the subjacent cellular tissue by 
means of radiated incisions, in the manner recommended by the 
late Mr. Tyrrell. This surgeon believed that ulceration of the cor- 
nea in this disease was caused by the constriction of the conjunctival 
vessels, exercised by the chemosis ; that thus the vascular supply 
was cut off from the cornea, and that free incisions would afford 
relief by removing the strangulation. Division of the chemosed con- 
junctiva had been recommended and practised before his time, but 
the incisions had been made at random, while Mr. Tyrrell advised 
that they should radiate from the cornea, in order that they might 
at the same time be free, and yet avoid wounding the larger vessels. 
It is doubtful whether the hypothesis on which Mr. Tyrrell founded 
this practice is correct, and less favorable results on the whole have 



186 GONORRHEAL OPHTHALMIA. 

been obtained by others than appear to have resulted from it in 
his hands ; yet there can be no question of the advantage of these 
incisions in many cases, however we may explain their mode of 
action. The greatest benefit may be expected from them when the 
effusion beneath the conjunctiva consists chiefly of serum; at a 
later period when- the chemosis has become firm from a deposit of 
fibrin, they are less advantageous. 

The method of making these incisions, as recommended by Mr. 
Tyrrell, is as follows : The patient is to be seated in a low chair, 
supporting his head against the chest of the surgeon, who stands 
behind him; the upper lid is elevated by the forefinger of one hand 
as in the operation of extraction, while an assistant depresses the 
lower lid; the incisions are to involve the conjunctiva and subjacent 
cellular tissue; they should extend from the margin of the cornea 
towards the circumference of the globe like the radii of a circle, at 
the same time avoiding the position of the recti muscles, lest the 
larger conjunctival vessels be wounded; the surgeon, holding a 
cataract knife in his disengaged hand, enters its point, with its back 
turned towards the cornea, at the junction of the cornea and sclero- 
tica, and cuts from within outwards, making two incisions in each of 
the four spaces between the insertions of the recti muscles ; imme- 
diately after the operation, the flow of blood and serum is favored 
by the application of hot water for ten or fifteen minutes. 

If chemosis has already taken place, the surgeon should make 
these radiated incisions on his first visit, and, at the same time, freely 
scarify the palpebral conjunctiva. Within half an hour after the 
blood has ceased to flow, the whole inflamed surface should be freed 
from pus and brushed over with a camel's hair pencil dipped in a 
solution of nitrate of silver containing forty to sixty grains to the 
ounce, taking care to remove the residue of the solution by a free 
application of tepid water afterwards. The incisions and scarifica- 
tions are to be repeated every twenty-four hours, so long as the 
chemosis continues severe. 

At this visit, also, the attendant, who is to take charge of the case, 
should be instructed as to her duties, and the importance of her 
faithfully performing them. She should be made to look on while 
the surgeon goes through the process of opening and cleansing the 
eye, and be taught to follow his example. A syringe is sometimes 
recommended for the purpose of removing the pus. There are, 
however, two objections to the employment of this instrument: in 



TREATMENT. 187 

the first place, unless used with gentleness, the force of the stream 
irritates the inflamed and sensitive conjunctiva ; and, again, the in- 
jected fluid, mixed with contagious matter, may be reflected back, 
and strike the eye of the attendant or fall upon the opposite eye of 
the patient. Several cases are recorded in which this accident has 
occurred. For these reasons a soft rag is to be preferred, and this, 
again, is better than a sponge, because it is more cleanly and may 
be frequently changed. By squeezing the fluid from the rag upon 
the adherent portions of the discharge, or by gently touching them 
with a free fold of the cloth projecting beyond the fingers, they can 
readily be detached. Simple tepid water may be used for these 
ablutions, but I prefer a solution of alum, of the strength of a drachm 
to the pint. The nurse should be directed to repeat them every 
hour or every half hour, according to the severity of the case, and 
the patient may be furnished with a cupful of the solution to bathe 
the external surface of the eye and wash away the discharge, still 
more frequently. Cleanliness may be still farther promoted by 
cutting off the ciliae, so as to prevent their becoming incrusted 
with matter ; and by smearing the edges of the lids with simple 
cerate. 

The strong solution of nitrate of silver, already mentioned, may 
be reapplied by the surgeon twice a day when he makes his visits, 
but, meanwhile, a weaker solution of the same salt, containing ten 
grains to the ounce, should be dropped into the eye, after it is 
thoroughly cleansed, every two or three hours. The patient must 
not be deprived of sleep by too frequent repetition of these measures 
during the night, but he should be provided with a watcher, who 
will cleanse the eye and apply the solution of nitrate of silver every 
few hours. If necessary, sleep must be promoted by the adminis- 
tration of an opiate. 

The time has gone by, when mercurials were thought requisite 
in this disease, on account of its supposed syphilitic origin. The 
only circumstance which can justify their employment is the pre- 
sence of a firm, fleshy chemosis, which, owing to its consistency, 
cannot be relieved by Tyrrell's incisions. In such cases, mercurials 
may perhaps hasten the absorption of the fibrinous deposit ; but 
they should be used with great caution, especially when ulceration 
of the cornea has already commenced, and should never be pushed 
to salivation. An excellent formula, combining the "gray powder" 
with quinine, is the following : — 



188 GONORRHEAL OPHTHALMIA. 

I£. Hydrarg. cum creta gr. ij. 
Quinise sulphatis gr. j-iv. 
Misce et ft. pulv. 
One to be taken morning and night. 

When only one eye is affected, the greatest care should be taken 
to avoid inoculation of the other by allowing the discharge to come 
in contact with it. On the slightest indication of inflammation in 
the latter, the weaker solution of nitrate of silver should be applied 
to it, as frequently as to the eye first affected. 

When there is excessive oedema of the lids, it may interfere with 
opening the eye and cause pressure upon the globe; in which case 
relief may be given by puncturing the skin in several places with 
a lancet. Division of the external canthus, in order to facilitate the 
exposure of the inflamed conjunctiva, has been recommended by 
Mr. France 1 and others, but it is not generally required. 

As the symptoms improve, the stronger solution of nitrate of 
silver may be omitted, and the weaker applied less frequently. 
When the chief danger is passed, the collyrium may often be changed 
with benefit, and one of the following substituted : — 

I£. Zinci sulphatis gr. ij. 

Glycerin 5ij« 

Vini opii 5j» 

Aquse 3 V « 
M. 

]fy. Acidi gallici gr. x. 

Glycerin 5iij« 

Vini opii 31 j. 

Aquse camphorse q. s. ad §iv. 
M. 

A pleasant method of employing these collyria is by means of an 
eye-cup. I have met with cases in which a solution of nitrate of 
silver appeared to irritate the eye, and in which the above collyria 
were found preferable even in the acute stage of the disease. 

The occurrence of an ulcer upon the cornea is of serious moment, 
and the friends of the patient should be informed of the danger to 
vision. 

The progress of the ulcer may sometimes be arrested by gently 
touching its surface with a stick of nitrate of silver, the point of 
which has been rounded off and somewhat sharpened by rubbing it 
upon a wet rag ; or a saturated solution of the same salt may be 

1 Guy's Hospital Reports, third series, vol. iii. 



TREATMENT. 189 

applied with a fine camel's hair pencil. The whitening of the sur- 
face which follows the application will indicate whether the whole 
of the ulcer has been touched. At the same time the pupil should 
be dilated by dropping a solution of atropine upon the globe once 
a day, or by smearing extract of belladonna, moistened with glyce- 
rin, around the orbit. The former is much more cleanly. The 
usual strength of the solution employed is two grains to the ounce; 
the atropine should first be dissolved in a drop or two of vinegar. 
The object of thus dilating the pupil is to diminish the prolapse of 
the iris if the ulcer should penetrate through the cornea, and, if pos- 
sible, to prevent the pupil's becoming involved in the resulting 
synechia. The chances of accomplishing this are not very great, 
for a pupil dilated by mydriatics contracts as soon as the aqueous 
humor escapes, as is seen during the operation of extraction for 
cataract; still, as the evacuation of the contents of the anterior 
chamber in perforating ulcer of the cornea is often sudden, some 
hope may be entertained of limiting the prolapse. I would again 
remind the reader of the importance of avoiding antiphlogistic 
remedies, and of the necessity of supporting the strength, when the 
cornea, a tissue of low vitality, is attacked by the ulcerative process. 
Cupping, leeching, low diet, and mercurialization will be sure to 
hasten destruction of the eye, which can only be saved, if saved at 
all, by generous living, stimulants, and tonics. 

A granular condition of the palpebral conjunctiva is frequently 
left after an attack of gonorrhoeal ophthalmia, and may keep up a 
slight discharge and irritation of the eye for a considerable time. 
The best means for its removal consists in the application of a crys- 
tal of sulphate of copper to the everted lids every second or third 
day ; and the general system should, at the same time, be supported 
by fresh air, good diet, and tonics. . 

"When a staphyloma is formed, its friction against the lids is often 
a source of irritation to the affected eye, and, through sympathy, to 
its fellow. If it is small, there may be hope of its contracting and 
being less prominent, as the fibrin covering it becomes more firmly 
organized ; and it may be pencilled over daily with a strong solution 
of nitrate of silver with a view of favoring this result. When, 
however, it has already attained considerable size, and covers so 
large a portion of the cornea that there is no chance of the eye 
serving as an organ of vision in future, it is useless to make any 
farther attempts to save the eye, especially as its inflamed condition 



190 GONORRHOEAE OPHTHALMIA. 

endangers the integrity of its fellow, and the intraocular pressure 
will probably still farther increase the size of the staphyloma, until 
it bursts of itself or is relieved by art. Two operations are avail- 
able under these circumstances : one, the ordinary excision of the 
staphylomatous projection and sinking of the eye; the other, extir- 
pation of the globe by the modern or Bonnet's method. 

The former is to be preferred, as a general rule, in cases of sta- 
phylomata following gonorrhceal ophthalmia, because the staphyloma 
is usually limited to the cornea, and the deeper tissues of the eye 
are commonly, though not always, sound. Moreover, the mobility 
of an artificial eye is greater when worn upon a sunken globe, than 
when the latter is removed; and, again, patients, through ignorance 
of the simple modern operation for extirpation, are very averse to 
its performance. At the same time, it should be recollected that a 
sunken eye, especially when irritated by wearing a glass substitute, 
may at any future period become inflamed and endanger the integ- 
rity of its fellow through sympathy. After the removal of a sta- 
phyloma, therefore, patients should always be warned of this dan- 
ger, and cautioned to seek advice at once, if ever the stump should 
become inflamed, or the sight of the fellow eye should begin to 
fail. 1 

The operation for removing a staphyloma is too well known to 
require description here. There is only one point to which I desire 
to call attention. After the operation, the lids should be closed by 
strips of isinglass plaster and remain so until the wound has entirely 
healed; otherwise the friction of the lids and the exposure of the 
hyaloid membrane to the air, will be likely to set up inflammation 
in the deeper tissues of the eye and cause much suffering. 

Extirpation of the globe should be preferred, when internal or 
general ophthalmia has supervened; when the staphyloma includes 
not only the cornea but a portion of the sclerotica ; or when hemor- 
rhage has taken place from the bottom of the eye, either on the 
perforation of the anterior chamber, on the bursting of the sta- 
phyloma, or during an operation for its removal. The blood, in 
these cases, comes chiefly from the choroidal vessels ; its flow may 

1 Calcareous deposit is very liable to take place in sunken globes which have 
become the seat of chronic inflammation, and in such cases it is impossible to 
relieve the irritation except by extirpation. I have this day removed the stump 
of an eye, destroyed by granular conjunctivitis, in a boy aged 16, in which I found 
a plate of calcareous matter the size of a three cent piece. 



TREATMENT. 191 

be arrested, but the clot can only be eliminated by the slow and 
tedious process of suppuration, and it is better to remove the eye 
at once. 

The modern operation for extirpation of the globe is exceedingly 
simple. The ball of the eye is alone removed, while the remaining 
contents of the orbit are left. The instruments required are a pair 
of toothed forceps, blunt-pointed straight scissors, and a strabismus 
hook. The eye should be kept open with a wire speculum. The 
conjunctiva and underlying fascia are divided close around the 
margin of the cornea, and the tendons of the four recti muscles 
hooked up and severed as in an operation for strabismus. The 
scissors are then passed in behind the globe and the optic nerve cut 
at its point of entrance, when the ball may readily be removed, after 
dividing the oblique muscles and any remaining points of attach- 
ment. There is no danger of subsequent hemorrhage. The lids 
may be allowed 'to close, and the clot which forms within them is 
the best hemostatic for such cases. If the operation has been well 
performed, without extending the incisions beyond the ocular fascia, 
the wound will heal with great rapidity. I have frequently been 
able to insert an artificial eye on the third or fourth day after the 
operation. 1 

The remedies recommended in the preceding pages for gonorrhoeal 
ophthalmia may be recapitulated, in the order of their importance, 
as follows: cleanliness, frequent application of an astringent solu- 
tion, nourishment, and, in most cases, stimulants and tonics, radiated 
incisions of the chemosed conjunctiva, cathartics, and local depletion. 
This plan of treatment differs widely from the copious and repeated 
venesections, the low diet, and the free administration of mercurials 
and tartar emetic, prescribed by nearly all writers on this affection 
until within a very few years. If the practice which I have advised 
were new, it might be requisite to say something farther in its de- 
fence ; but its claims have already been established by most of the 
eminent authorities of what may be called the modern school of 
ophthalmic surgery. When supported by the writings and practice 

1 It would be out of place in this work to enter more fully into the details of 
this and other operations which may be required after gonorrheal ophthalmia. 
For farther particulars with reference to extirpation of the globe, the reader is 
referred to an essay by Mr. Critchett, in the London Lancet (Am. ed.), Jan. 1856 ; 
also to papers by Dr. C. R. Agnew and by the present writer, in the N. Y. Journal 
of Med., Jan. and May, J859. 



192 GONORRHEAL OPHTHALMIA. 

of such men as Prof. Graves/ Critchett, 2 Bowman, Wilde, Dixon, 3 
France, 4 Hancock, 5 and others, both in this country and abroad, it 
is unnecessary to say anything farther in its favor. I will only add 
that my own experience, drawn from the largest infirmary for dis- 
eases of the eye in this country, perfectly coincides with that of the 
authors above mentioned. 6 

In the words of Mr. Dixon : " The student ought constantly to 
bear in mind that, although the disease termed purulent ophthalmia 
has received its name from that symptom which readily attracts 
notice, namely, the profuse conjunctival discharge, the real source 
of danger lies in the cornea; and that, even if it were possible so 
to drain the patient of blood as materially to lessen or even wholly 
arrest the discharge, we might still fail to save the eye. It is not 
the flow of pus or mucus, however abundant, that should make us 
anxious, but the uncertainty as to whether the vitality of the cornea 
be sufficient to resist the changes which threaten its transparency. 
These changes are twofold — rapid ulceration and sloughing. Now, 
has any sound surgeon ever recommended excessive general bleed- 
ing and salivation as a means of averting these morbid changes 
from any other part of the body except the eye ? And if not, why 
are all the principles which guide our treatment of other organs to 
be thrown aside as soon as it attacks the organ of vision?" 

1 London Medical Gaz., vol. i., 1838-9, p. 361. 

2 Lectures on Diseases of the Eye, London Lancet (Am. ed.), Aug. 1854. 

3 Guide to the Practical Study of Diseases of the Eye. London, 1859. 

4 Op. cit. 5 London Lancet, Nov. 1859. 

6 Dr. O'Halloran appears to have been one of the first to discard the old depletive 
treatment of purulent ophthalmia. In his " Practical Remarks on Acute and 
Chronic Ophthalmia, and on Remittent Fever" (London, 1824), he says : " I am of 
opinion that if any inquiry be instituted amongst the army surgeons, it will be 
found that those who used the greatest depletion were the least successful practi- 
tioners, and that sloughing, ulcers, &c, more fr queutly succeeded the evacuating 
plan than when the patient was partly left to nature." 






GONORRHEAL RHEUMATISM. 193 



CHAPTER XI. 

GONORRHEAL RHEUMATISM. 

Gonorrheal rheumatism was first recognized by Swediaur, who 
described it under the name of " Arthrocele, Gonocele, or Blennor- 
rhagic Swelling of the Knee." 1 Since Swediaur's time, this disease 
has received particular attention from various writers on venereal 
and diseases of the joints, among whom Sir Benjamin Brodie, 2 Sir 
Astley Cooper, 3 Eicord, 4 Bonnet, of Lyon, 5 Foucart, 6 Brandes, 7 and 
Eollet, 8 are especially worthy of mention. During this period, 
however, gonorrhoeal rheumatism has by no means been allowed to 
retain its place in the nosological system undisturbed, and there 
have been many who have attempted to explain it away, on various 
hypotheses. Its claims to be considered a distinct complication of 
gonorrhoea will appear in the course of this chapter. 

To an observer who had never heard of the connection between 
gonorrhoea and rheumatism, it might indeed appear a mere coinci- 
dence, if a patient suffering from gonorrhoea should suddenly be 
seized with inflammation of the joints ; but should this same pa- 
tient, after entirely recovering from both affections, and after seve- 
ral years of perfect health, again contract gonorrhoea, and again be 
seized with articular rheumatism, the occurrence would be suffi- 
ciently remarkable to excite a suspicion in the mind of the most 

1 A Complete Treatise on the Symptoms, etc., of Syphilis, by F. Swediaur, M. D. 
Translated from the fourth French edition, by Thomas T. Hewson. Philada., 1815, 
p. 108. 

2 Brodie's Select Surgical Works : Diseases of the Joints. Philada., 1847. 

3 Lectures on the Principles and Practice of Surgery. London, 1835, p. 482. 

4 Notes to Hunter, 2d ed. Philada., 1859, p. 275. 

5 Traite des Maladies Articulaires. Paris, 1853, t. i. p. 376. 

6 Quelques Considerations pour servir a l'Histoire de l'Arthrite Blennorrhagique ; 
in 8vo. pp. 45. Bordeaux, 1846. 

7 Archives Generates de Medecine, Sept. 1854. 

8 Annnaire de la Syphilis ; annee 1858, Lyon. 

13 



194 GONORRHEAL RHEUMATISM. 

careless observer that there was some connection between the two. 
Let this second attack be followed by a third, fourth, and fifth, and 
the suspicion would be converted into a very strong probability. 
Suppose that numerous other patients were met with in whom these 
two affections thus repeatedly coexisted, an attack of gonorrhoea 
in each of them being followed by one of rheumatism, with such 
certainty that the latter might be predicted immediately on the ap- 
pearance of the former, and a manifest relation between the two 
diseases could no longer be doubted. Now, this repetition of these 
two diseases in the same person is not merely hypothetical — it is a 
reality ; and it is observed in subjects entirely free from any rheu- 
matic diathesis, who have inflammation of the joints at no other 
time than when they have gonorrhoea. Among the many cases 
which might be cited, none perhaps will better illustrate this point 
than the following, which I quote from the lectures of Sir Astley 
Cooper : — 

" I will give you," says this distinguished surgeon, " the history 
of the first case I ever met with ; it made a strong impression on 
my mind. An American gentleman came to me with a gonorrhoea, 
and after he had told me his story, I smiled, and said : do so and 
so (particularizing the treatment), and that he would soon be better ; 
but the gentleman stopped me, and said, ' Not so fast, sir ; a gonor- 
rhoea with me is not to be made so light of — it is no trifle ; for, in 
a short time you will find me with inflammation of the eyes, and in 
a few days, I shall have rheumatism in the joints ; I do not say this 
from the experience of one gonorrhoea only, but from that of two, 
and on each occasion I was affected in the same manner.' I begged 
him to be careful to prevent any gonorrhoeal matter coming in con- 
tact with the eyes, which he said he would. Three days after this 
I called on him, and he said, ' Now you may observe what I told 
you a day or two ago is true.' He had a green shade on, and had 
ophthalmia in each eye ; I desired him to keep in a dark room, to 
take active aperients, and apply leeches to the temples. In three 
days more he sent for me, rather earlier than usual, for a pain in 
one of his knees ; it was stiff and inflamed ; I ordered some appli- 
cations, and soon after the other knee became inflamed in a similar 
manner. The ophthalmia was with great difficulty cured, and the 
rheumatism continued many weeks afterwards." 

Similar cases are related by nearly every author who has written 
on this affection, and, further on, many are given in a table of the 



CAUSES. 195 

diseases of the eye which accompany gonorrhoeal rheumatism. M. 
Rollet . relates in detail five such instances occurring in his own 
practice, and this repetition took place in eight of thirty -four cases 
reported by Brandes, of Copenhagen, and in three of eight cases 
observed by M. Diday. According to Eollet's researches, this repe- 
tition has been noted in nearly one quarter of the total number of 
cases of gonorrhoeal rheumatism which have been published. 

The frequency of cases like these can leave no doubt in the 
mind that a close relation exists between these two affections, and 
additional evidence is found in the fact that the rheumatism attend- 
ant upon gonorrhoea presents certain peculiarities, which, in general, 
are sufficient to distinguish it from the ordinary forms of rheuma- 
tism. 

Causes. — In comparison with the great frequency of gonorrhoea, 
gonorrhoeal rheumatism is exceedingly rare. Yery little is known 
of the causes which occasion it in the few, while the many affected 
with gonorrhoea escape. Its occurrence might naturally be attrib- 
uted to a rheumatic diathesis, especially as the fact is well estab- 
lished that persons subject to rheumatism are particularly prone 
to contract gonorrhoea; and it is distinctly asserted by several 
writers that a constitutional tendency to rheumatism is a predis- 
posing cause of inflammation of the joints during an attack of 
gonorrhoea. There is reason to believe, however, that the plausi- 
bility of this opinion, founded on & priori reasoning, has given it 
greater weight than it deserves. Those who have expressed it, 
have failed to produce any evidence in its support; and if we 
examine the published cases of this disease, we frequently find it 
noted that the patient never suffered from rheumatism except when 
he had gonorrhoea. M. Rollet has made this point a special subject 
of inquiry, and states that in the great majority of cases of gonor- 
rhoeal rheumatism which have come under his observation, there 
was no rheumatic diathesis either in the patients or in their parents. 
He also states that he has had under treatment many patients with 
gonorrhoea, who were predisposed to rheumatism, and yet in them, 
urethritis has not been attended by any inflammation of the joints ; 
and this fact derives additional weight from the frequency with 
which gonorrhoeal rheumatism, after having once occurred, is re- 
excited by a subsequent clap. These statements of M. Rollet go 
far to show that a rheumatic diathesis has no part in the production 



196 GONOEEHCEAL EHEUMATISM. 

of gonorrhoeal rheumatism ; it is desirable, however, that this point 
should be subjected to further observation. 1 

The exciting cause of gonorrhoeal rheumatism cannot be found 
in the use of copaiba and cubebs, as has been sometimes asserted, 
or in exposure to cold and sudden changes of temperature. In- 
flammation of the joints has frequently been known to occur in 
patients who have taken neither of these drugs, and who have 
been confined to the wards of a hospital during the whole course 
of their attack of gonorrhoea. On the other hand, how frequently 
are copaiba and cubebs administered for gonorrhoea, and how often 
must the subjects of clap be exposed to cold and moisture, and 
yet how rare is gonorrhoeal rheumatism ! 

The phenomena of gonorrhoeal rheumatism are also inconsistent 
with the idea of a metastasis from the urethra to the joints, since 
in most cases there is an exacerbation of the urethral discharge 
preceding the articular inflammation. This is especially noticeable 
in chronic cases of gleet, in which gonorrhoeal rheumatism super- 
venes. 

The influence of sex in the production of gonorrhoeal rheuma- 
tism cannot be questioned. All the undoubted cases of this 
disease that have been published relate to men, and it must be 
extremely rare, if it exists at all, in women. 2 Eicord, Yidal, and 

1 M. Rollet weakens his position by asserting an antagonism between a rheu- 
matic diathesis and gonorrhoea, in virtue of which, he believes that a clap some- 
times cures a patient of a tendency to rheumatism, from which he has previously 
suffered for years ! He says that he has observed one such case, and quotes another 
in detail which occurred in the practice of M. Diday ; but surely it is more 
reasonable to suppose that the disappearance of the rheumatism in these two 
cases was a mere coincidence. 

2 Foucart says : " I have not been able to find a single case of gonorrhoeal rheu- 
matism in the female, either in special treatises on this subject or in the medical 
journals." 

Brandes says- : " The cases of gonorrhoeal rheumatism reported by a few authors 
are far from conclusive. My own attention has been fixed on this point for six 
years, during which time I have not been able to find a single case at the only 
hospital in Copenhagen where venereal diseases in women are treated." 

Two very questionable cases are reported as occurring in the service of M. Rayer 
in 1846, the only account of which is as follows : " One woman was affected with 
inflammation of the elbow joint during the course of an attack of vaginitis. 
Another had nearly all the joints of the extremities slightly and successively 
inflamed, after several attacks of vaginal discharge." (Rollet.) 

Another questionable case is related by MM. Blatin and Nivet (Traite des Mala- 
dies des Femmes). 



SEAT. 197 

a few other writers admit that it is occasionally met with in women, 
but have not reported any cases. 

It will be seen from the above remarks how imperfect is our 
knowledge of the etiology of this disease, and it would be useless 
to enter into any farther speculations upon the subject. 1 

Seat. — None of the joints are exempt from an attack of gonor- 
rhoea! rheumatism, but this disease affects the knee far more 
frequently than any other joint. The following table exhibits the 
order of frequency with which the various joints were affected 
in 81 cases observed by MM. Foucart, Brandes, and Eollet: — 

Articulation of the knee 64 

" ankle ....:. 30 

: < hips 15 

:< fingers and toes . . . . . 15 

' shoulder ...... 10 

' wrist ....... 10 

!< elbow 8 

il sternum and clavicle ... 3 

" tarsal bones 2 

il sacrum and ilium .... 2 

' lower jaw ...... 1 

; ' tibia and fibula 1 

161 

Thus in 81 cases 161 joints were affected, and the knee was 
involved in 64. Besides the joints, gonorrhoeal rheumatism fre- 
quently affects the ocular tunics ; also the bursae connected with 
the muscular tendons, especially the tendo- Achillis ; and some- 
times the sheaths of the muscles, as in muscular rheumatism. 
Again, Eicord states that he has met with several patients who 
suffered from severe pain in the plantar region, apparently seated 
in the fasciae. 

The knee-joint, therefore, is the favorite seat of gonorrhoeal 
rheumatism, though all the joints of the body are liable to its 
attacks. This disease, however, is less prone to change its seat 
from one joint to another than ordinary articular rheumatism. 

1 Rollet is inclined to believe that an explanation of the origin of gonorrhoeal 
rheumatism is to be sought for in the seat of gonorrhoea. He says : " There is no 
difficulty in admitting that when gonorrhoea extends to certain tissues or portions 
of the urethra, as yet undetermined, it may, in subjects constitutionally predis- 
posed to this disease, excite inflammation of the joints." 



198 GONORRHEAL RHEUMATISM. 

This fact is evident from an examination of the above table, which 
shows that there were but 161 joints affected in 81 cases ; an aver- 
age of about two joints to each case. I know of no similar table 
exhibiting the number of articulations affected in a given number 
of cases of ordinary rheumatism, but the proportion is undoubtedly- 
much greater. Again, in 10 of the 19 cases in the above table, 
furnished by M. Foucart, only one joint was affected ; of the 34 cases 
of M. Brandes's, the rheumatism was mono-articular in 5, and also 
in 10 of the 28 cases collected by M. Kollet. These facts, therefore, 
would give us a ratio of about one-third, in which gonorrhoeal 
rheumatism attacks but a single joint, but more extended statistics 
are required before this proportion is received as accurate. 

Even when gonorrhoeal rheumatism does not remain confined to 
one joint, but extends to others, the articulation first affected does 
not recover its normal condition, as it often does in ordinary articu- 
lar rheumatism, but generally continues in a state of inflammation 
after the disease is lighted up in other joints. In this respect, 
gonorrhoeal rheumatism again differs from acute rheumatism, but 
approximates to the character of rheumatic gout. 

There can be no question, I think, that gonorrhoeal rheumatism 
sometimes attacks the heart, but it is equally certain that this 
complication is much less frequently met with than in ordinary 
acute articular rheumatism. 1 Eicord states that in several clearly 
marked cases of gonorrhoeal rheumatism, he has observed symptoms 
of endocarditis, and also of effusion within the pericardium, and it 
is to be regretted that he has not given these cases in detail. The 
rarity of any mention of heart disease, however, in the reported 
cases of gonorrhoeal rheumatism, proves the correctness of the above 
assertion that this disease is usually free from such complication. 
The only undoubted case that I am acquainted with is one reported 
by Mr. Brandes : — 

A man, 50 years of age, had had five attacks of gonorrhoea within 
ten years ; each attack being attended with disease of the joints. 
In a sixth attack he was seized with violent pain and swelling of 
several joints, especially the knee. A few days after, inflammation 
of the eye and pericardium ensued. The friction sound was well 
marked ; and the pulsations of the heart were irregular. There was 

1 "I am induced to think that, under ordinary circumstances, some heart 
affection arises in about half of all cases of acute rheumatism." {Fuller on 
Rheumatism.') 



SYMPTOMS. 199 

dulness on percussion over a considerable space, with palpitation 
and pain in the precordial region. These symptoms improved 
under venesection and mercurials. Meanwhile the iris became 
inflamed in the right eye, and a week after this eye recovered, the 
left was attacked. The patient finally recovered, but suffered from 
weakness of the lower extremities for a long time, so that he was 
obliged to walk with crutches for several months. 

I have also received a verbal report of a similar case occurring 
in the practice of one of the most reliable surgeons of this city, but 
the details, drawn only from memory, are not sufficiently full to 
entitle them to publication. 

Eicord is the only authority, so far as I am aware, who has seen 
any affection of the nervous centres in gonorrhceal rheumatism. 
This surgeon states that he has met with symptoms of compression 
of the spinal marrow and of the brain, such as paraplegia and 
hemiplegia, which appeared to be produced by increased effusion 
within the serous membranes of the brain and spine, and which 
followed the same course as the affection of the joints. 

No affection of the lungs or pleura has ever been observed in 
gonorrhceal rheumatism. 

Gonorrhceal rheumatism is essentially an hydrarthrosis, and in 
many instances the inflammation is confined to the synovial mem- 
brane of the joint during the whole Course of the affection. The 
predilection of this disease for serous membranes is shown by its 
attacking the bursas connected with the tendons, especially about 
the wrist and ankle. Rollet states that he has seen one case in 
which the seat of the disease appeared to be a bursa accidentally 
developed over the acromion process. 

Symptoms. — In describing the symptoms of gonorrhceal rheu- 
matism, it is desirable to take those of ordinary articular rheumatism 
as a standard of comparison. Proceeding in this manner, we find 
that gonorrhceal rheumatism is generally ushered in with less febrile 
disturbance than its more frequent congener. In some cases there 
is an entire absence of premonitory symptoms, and the patient's 
attention is not attracted to the joints until effusion has taken place 
and motion has thereby been rendered painful and difficult. In 
other instances, a slight chill and wandering pains have been ex- 
perienced, before the morbid action has become settled in any one 
joint; and those cases are exceptional in which the inflammatory 



200 GONORRHCEAL RHEUMATISM. 

symptoms at the outset are comparable in violence to those of acute 
rheumatism. 

When the articular disease is fairly established, the pain is in- 
creased and is often severe ; but here, also, we find the symptoms 
less acute, as a general rule, than in ordinary rheumatism. Even in 
those cases in which the local pain is great, there is much less general 
febrile excitement; and an examination of the blood drawn in five 
cases by M. Eollet and in one by M. Foucart, failed to show that 
buffed and cupped condition of the clot which is so frequently met 
with in acute rheumatism. 

The integument covering the affected joint generally retains its 
normal color, though it sometimes puts on the blush of inflamma- 
tion. When the knee-joint is the seat of the disease, as is fre- 
quently the case, the symptoms of a serous effusion within the 
capsule are readily detected. The patella is elevated above the 
femur and is freely movable ; the joint has the form of a cube, the 
usual depression on either side of the patella being replaced by 
swellings, and fluctuation can be detected without difficulty. It is 
evident that the inflammatory process is confined to the synovial 
membrane, and that the fibrous and osseous tissues are unaffected. 
The collection of serum necessarily impairs the mobility of the joint, 
and pain is excited by pressure or by any attempt at motion. If 
the disease do not yield readily to treatment, other tissues about the 
joint become involved, and we may then find redness of the skin, 
together with fulness of the vessels and a corresponding increase of 
the pain and general febrile disturbance, assimilating the case to 
one of acute rheumatism. 

Those cases of gonorrhceal rheumatism which commence with 
the most decided inflammatory symptoms are generally the most 
amenable to treatment ; those, on the contrary, in which the febrile 
action is but slight, and in which there is but little more than a 
passive effusion into the synovial sac, are more obstinate. 

Eecovery, in any case of this disease, can rarely be expected in 
less than a month or six weeks, and is often delayed for several 
months or even years, especially when the patient is debilitated and 
when the affection of the urethra is allowed to run on, or does not 
yield to treatment. 

It is unnecessary to describe the symptoms of the cardiac affec- 
tion which sometimes complicates a case of gonorrhceal rheumatism, 
since these do not differ from those of endocarditis and pericarditis 



SYMPTOMS. 201 

attendant upon ordinary acute rheumatism. The inflammation of 
the eye which frequently precedes or accompanies — or sometimes 
alternates with the disease of the joints, and which is evidently de- 
pendent upon the same condition of the general system, will presently 
receive special mention. 

Most cases of gonorrhceal rheumatism terminate sooner or later 
in complete resolution, although they may render the patient a 
cripple for a long period. Suppuration within the bursa very rarely 
occurs. MM. Velpeau, Foucart, Bonnet, Brandes and Eollet state 
that it never takes place; it is admitted by Eicord, who says, how- 
ever, that it is always due to some accessory cause of inflammation ; 
and Yidal mentions one case occurring under his charge in which 
it was necessary to open the joint and evacuate the purulent collec- 
tion. Anchylosis, especially of the smaller joints, is a more frequent 
termination of gonorrhceal rheumatism, and in scrofulous subjects, 
this disease has not unfrequently been followed by that strumous 
affection of the joints known as "white swelling;" here, as in other 
well-known instances, a constitutional cachexia selects the weakest 
part of the body as the seat of its manifestation. 

Dr. Holscher 1 reports a case in which death is said to have oc- 
curred from gonorrhceal rheumatism. An abscess formed in the 
affected joint, and purulent infection ensued. 

The period at which rheumatism makes its appearance in the 
course of a gonorrhoea appears to be more variable than that of 
epididymitis. Some cases are met with in which the affection of 
the joints occurs during the acute stage, or first week or two of the 
duration of the clap ; and yet in the majority of cases we find that 
the rheumatism manifests itself at a later period, when the urethral 
discharge has passed its climax. Generally, we find that the run- 
ning has been more copious for a few days preceding the outbreak 
of the rheumatism, and this is especially noticeable in long-standing 
cases of clap which have been accompanied by several repetitions 
of the articular affection, each of which has followed an exacerba- 
tion of the discharge. Cases in which the running suddenly di- 
minishes or entirely dries up before the rheumatism appears, must 
be regarded — in spite of the opposite opinion so frequently ex- 
pressed — as rare and exceptional, and not sufficient for the basis 
of a theory of metastasis. In deciding this point — to which much 

1 Annales de Holscher, 1844. 



202 GONOKRHCEAL RHEUMATISM. 

importance has been attached — it should be recollected that if the 
rheumatism occurs several weeks after contagion, the discharge will 
probably have somewhat diminished, following the course which it 
usually pursues in cases entirely free from any complication. After 
the disease of the joints is established, the running sensibly de- 
creases in most cases, as a consequence of revulsive action. In 
other instances — estimated by Eollet at about one-third — it remains 
without much change. It rarely disappears entirely, except as the 
result of treatment. 

Gonorrhoeal rheumatism, unlike acute rheumatism, but like rheu- 
matic gout, frequently attacks the eye. 1 The ocular affection in 
these cases, is that form of "gonorrhoeal ophthalmia" which has 
been described by authors as " metastatic or sympathetic ;" but the 
difference in the mode of origin, symptoms, prognosis, and treat- 
ment, between this form of ophthalmia and purulent conjunctivitis 
arising from contagion, is so great, that it would be desirable to dis- 
tinguish the two by different names, and to drop altogether the 
term gonorrhoeal ophthalmia, as applied to that ocular affection 
which accompanies gonorrhoeal rheumatism. But before proceeding 
to further discussion of this point, it will be interesting and instruc- 
tive to compare the views of different authors relative to these two 
diseases. 

Mr. Tyrrell 2 denies the existence of gonorrhoeal ophthalmia allied 
to purulent conjunctivitis and arising in any other way than by 
contagion, but he admits a conjunctivo-sclerotitis, due, as he sup- 
poses to the metastasis of gonorrhoea. 

Mackenzie admits gonorrhoeal conjunctivitis by contagion, by 
metastasis and by sympathy, and also a gonorrhoeal iritis. 

Mr. Lawrence 3 admits three distinct forms of ophthalmic inflam- 
mation occurring in conjunction with, or depending on gonorrhoea, 
viz., 1st. Acute inflammation of the conjunctiva; 2d. Mild in- 

1 " In true rheumatism, the eye seldom suffers ; so seldom, that I find no record 
of any affection of that organ in more than 4 out of the 379 cases of acute and 
subacute rheumatism admitted into St. George's Hospital, during the time I held 
the office of Medical Registrar. But in rheumatic gout, the eye is not unfrequently 
implicated. It was inflamed in 11 out of the 130 cases of rheumatic gout admit- 
ted during the same period : and it has suffered more or less severely in 5 out of 
75 cases, which have fallen under my own care at the hospital." (Fuller.) 

1 Diseases of the Eye, vol. i. p. 387. 

3 On the Venereal Diseases of the Eye, London, 1830. 



SYMPTOMS. 203 

flammation of that membrane ; and 3d. Inflammation of the scle- 
rotic coat, sometimes extending to the iris. 

In speaking of the last mentioned form, Mr. Lawrence says: 
" This affection of the eye is exactly the same as rheumatic inflam- 
mation of the sclerotic and iris, occurring independently of gonor- 
rhoea. Both this and the mild purulent inflammation of the con- 
junctiva are to be regarded as rheumatic affections of the organ 
excited by gonorrhoea ; that is, they take place in individuals, in 
whom this constitutional disposition is shown by inflammation 
affecting either the synovial membranes, or the fibrous structures 
of the joints. Although the organs seem at first view very dissi- 
milar, there is an analogy of structure between the parts which 
suffer in the two instances ; that is, between the synovial membranes 
and the conjunctiva, and between the ligaments and fibrous sheaths, 
and the sclerotica. Hence, we need not be surprised at finding that 
the eyes suffer under the influence of that unsound state of consti- 
tution which leads to these affections of the joints. The structure 
originally affected, the lining of the urethra, is also a mucous mem- 
brane, which sometimes becomes inflamed, and pours out a puri- 
form discharge, in gouty and rheumatic subjects from internal 
causes." 

Ricord admits two kinds of gonorrhoeal ophthalmia ; one from 
contagion, the other metastatic or sympathetic; but although he 
states that the latter may present all the symptoms of the former, 
yet his description of it differs widely from uncomplicated purulent 
conjunctivitis. He says : " Not only the conjunctival, but also the 
sclerotic vessels are injected ; the eye appears more tense and more 
brilliant than natural ; the cornea often projects a little more than 
usual, and the iris is a little farther off; in some instances we may 
satisfy ourselves that the aqueous humor is increased. At times 
there are symptoms of iritis, as a change of color in the iris, con- 
traction of the pupil, which is rarely distorted, and more or less 
photophobia. The aqueous humor may be cloudy, lactescent, or 
flaky, owing to inflammation of the membrane of Descemet, and 
false membranes may be formed, which give rise to adhesions, or 
pseudo-cataracts ; but pustules on the iris, or what have been called 
condylomata of the iris, are never seen as in syphilitic iritis. A 
process takes place in the eye analogous to what we meet with in 
the synovial membranes, in cases of gonorrhoeal arthritis, which, as 
I have already stated, sometimes accompanies this ophthalmia, or 



204 GONORRHCEAL RHEUMATISM. 

alternates with it. Sympathetic gonorrhoeal ophthalmia, other 
things being equal, is more irregular in its course, and more subject 
to relapses than the ophthalmia from contagion. It often changes 
its seat, which does not occur in the latter." It will be seen that 
this description covers the symptoms of inflammation of the deeper 
textures of the eye, especially the sclerotica and iris, rather than 
those of uncomplicated conjunctivitis ; and, in spite of Kicord's sub- 
sequent statement that the symptoms of the sympathetic disease 
may be identical with those of gonorrhoeal ophthalmia from conta- 
gion, it is evident that he is describing a different affection. 

Finally, M. Eollet 1 has taken the ground that sympathetic gonor- 
rhoeal ophthalmia is almost always an inflammation of the mem- 
brane of Descemet, and that it is invariably a manifestation of 
gonorrhoeal rheumatism. This surgeon calls attention to the fact 
so frequently noticed by others, that this form of ophthalmia is 
generally associated with gonorrhoeal rheumatism, but he is also 
inclined to believe that it may exist alone without any affection of 
the joints, and that ■ as we often have one joint alone attacked by 
gonorrhoeal rheumatism, so the eye may be the only part of the 
body in which the rheumatic tendency shows itself. 

With regard to the seat of this affection, M. Eollet does not 
deny that it may be in some other of the ocular tunics, but he 
maintains, that in the great majority of cases, it is in the iris. He 
goes farther, and asserts that it is the anterior layer of the iris which 
is attacked by the inflammatory process, which may extend to the 
posterior lamina of the cornea. According to this author, there- 
fore, this affection is an aquo-capsulitis, or, more properly speaking, 
a kerato-iritis, the symptoms of which are the following : injection 
of the conjunctival vessels and especially of the zone of sclerotic 
vessels around the cornea ; occasional photophobia and increase in 
the flow of tears ; a nebulous appearance of the cornea ; an increase 
of the aqueous humor ; dulness of the iris, and a deposit of plastic 
material in the anterior chamber (which Mackenzie states is un- 
equalled in degree in any other form of iritis), occasioning great 
obscuration of vision. Generally both eyes are attacked simulta- 
neously or consecutively. The disease may terminate in resolution, 
or atresia iridis. It differs from syphilitic iritis, in that the latter 
affects the substance of the iris, produces a greater change in its 

> Op. cit. 



SYMPTOMS. 205 

color, often gives rise to tubercular excrescences, deforms the pupil 
to a greater extent, and is more likely to cause adhesions between 
the iris and anterior capsule of the lens. In the opinion of M. 
Kollet, the symptoms of gonorrhceal iritis now described are so 
constant, and so different from the effects of common rheumatism 
upon the eye, that he regards this affection as one proof that 
gonorrhceal rheumatism is a distinct species apart from rheumatism 
produced by other causes. 

It thus appears that several authors have recognized the fact 
that " sympathetic gonorrhceal ophthalmia" is dependent upon the 
same condition of the general system as gonorrhceal rheumatism. 
Moreover, in all the cases which I have been able to find recorded, 
these two diseases have coexisted within a short space of time ; the 
affection of the eye, in all of them, has been either preceded, at- 
tended, or followed by rheumatism, and in some instances they 
have alternated with each other. 

Again, the tissues of the eye affected are the same as those usu- 
ally involved in rheumatic gout, with which gonorrhceal rheuma- 
tism has so many other points of resemblance. These considerations 
are sufficient, I think, to establish the identity of the two diseases, 
and to authorize the conclusion that the affection of the eye is but 
one manifestation of gonorrhceal rheumatism. It is no objection 
to this view that the ophthalmia sometimes precedes the affection 
of the joints, for the same is true of inflammation of the heart 
attendant upon acute rheumatism, 1 and we may also admit, that 
in some cases, though I have not met with any such, the disease of 
the eye is the only evidence of a rheumatic tendency, the joints 
remaining entirely unaffected. 

The present classification of this form of ophthalmia, does away 
with many difficulties which have heretofore surrounded this sub- 
ject, and reconciles many discrepancies to be found in books. The 
"mild gonorrhceal conjunctivitis" of Lawrence, the "gonorrhceal 
conjunctivo-sclerotitis" of Tyrrell, and the "gonorrhceal iritis" of 
Mackenzie and others, are seen to be essentially the same disease, 

1 " In summing up the principal facts deserving of notice in reference to rheu- 
matic inflammation of the heart, I should say that it is incidental to all the stages 
of acute rheumatism, occurring sometimes before the commencement of inflam- 
mation of the joints, and possibly, also, in some rare instances, without the 
concurrence from first to last, of any active articular symptoms." {Fuller on Rheu- 
matism, Am. ed., N. Y. 1854, p. 165.) 



206 GONORRHEAL RHEUMATISM. 

dependent upon a rheumatic tendency induced by gonorrhoea, and 
capable of manifesting itself in any of the external tunics of the 
eye. The difficulty of admitting a disease of the eye originating 
in gonorrhoea, otherwise than by contagion, is done away with ; it 
is no longer necessary to call in question the cleanliness of patients, 
or to suspect constitutional syphilis in the entire absence of proof 
that such exists; and the obscure phenomena of metastatic and 
sympathetic gonorrhceal ophthalmia are found to be in accordance 
with the laws which govern ordinary rheumatic ophthalmia. 

In the following table of cases of gonorrhoeal rheumatic oph- 
thalmia, I have included all the more noted facts which from time 
to time have been published by some of the most eminent authori- 
ties in our profession. Most of them have been related by their 
authors as instances of "metastatic or sympathetic gonorrhoeal 
conjunctivitis, iritis," etc. In many cases, the details are very 
imperfect, and it is very probable that in some the disease of the 
eye was merely catarrhal ophthalmia coexisting with gonorrhoea, 
but I have thought it best to make no attempt to sift them, the 
better to enable the reader to form his own conclusions on the facts 
at present in our possession. This table includes, nearly all the 
cases which I have been able to find in a somewhat extended search 
through works on Venereal, and Diseases of the Eye. 



METASTATIC GONORRHEAL OPHTHALMIA. 



207 



REPORTED CASES OF 



METASTATIC GONORRHOEAE OPHTHALMIA' 
SO-CALLED. 



Brodie's Se- 
lect Surgical 
Works ; Dis- 
eases of the 
Joints; Phil., 
1847, p. 35. 



Ibid., p. 36. 



Patient 45 
years of age. 



Four 
at- 
tacks. 



Case obscure- 
ly reported. 



Ibid. 



37. 



Ibid., p. 37. 



Ibid., p. 38. 



Patient with 

strictures of 

urethra. 



Patient aetat 
23. 



Lawrence on John Harley, 



the Venereal 

Diseases of 

the Eye ; 

London, 

1830, p. 104. 

Ibid., p. 107. 



aged 38, had 

never had 

rheumatism 

before. 



Gentleman, 

52 years of 

age. 



Ibid., p. 111. 



Nine. 



Two. 



Four. 



One. 



One. 



Seve- 
ral. 



Mr G., aetat. 

33, of good 
constitution : 
had never suf 

fered from 
rheumatism. 



Contracted gonorrhoea in the middle of June, 1817. 
Rheumatism of foot commenced June 23; ophthal- 
mia June 24 ; conjunctivae much inflamed with 
profuse discharge of pus. Complete recovery. 

2d attack in Dec. 1817, similar to preceding, but 
leaving him crippled. 

3d and 4th attacks in March, 1818 and 1822, in 
which the inflammation was situated in the ' ' proper 
tunics" of the eye ^sclerotica, iris, and choroid). 

In four attacks, purulent ophthalmia ; in two inflam- 
mation of the sclerotica and iris ; inflammation of 
various joints and bursae mucosae. 

Gonorrhoea in 1809, with swelled testicle, purulent 
ophthalmia, and inflammation of synovial mem- 
branes. Similar attack in 1814, except no swell- 
ing of testicle. 

In all, the urethritis was the first symptom, and was 
followed by purulent ophthalmia and inflammation 
of synovial membranes. In two of the cases, the 
gonorrhoea was attributed to contagion, and in 
the two others to the use of bougies. 

Purulent discharge from the urethra ; inflammation 
of knee-joint with effusion ; slight inflammation of 
the conjunctiva, which subsided under the use of 
remedies directed to the rheumatism. 

One month after appearance of gonorrhoea was at- 
tacked with " acute external inflammation'' of 
both eyes, resulting in extensive ulceration of 
corneae and impaired vision ; within one week 
after commencement of ophthalmia, had rheuma- 
tism of several joints. 

Slight discharge from the urethra in 1822, which the 
patient did not attribute to infection, followed by 
inflammation of conjunctiva, chemosis, and puri- 
form discharge. The eye symptoms disappeared, 
when rheumatism of one knee and both hands set 
in ; as the latter grew better, the eyes became in- 
flamed again. This attack lasted for two years. 

The patient was seen again in 1828. No recurrence 
of acute rheumatism, though the joints were still 
stiff from old attack. Had had at least six attacks 
of inflammation of the eyes since former visit, and 
the contraction of pupils and adhesions to capsule 
showed that the iris had been involved. No return 
of urethral discharge. 

Urethral discharge appeared July 9th, 1827 ; eyes 
became inflamed July 23d ; symptoms those of 
simple acute conjunctivitis, without chemosis or 
profuse purulent discharge. Severe pain in the 
hip and thigh came on July 24th. Patient im- 
proved and was supposed to be well, but had a 
short relapse of urethral discharge, ophthalmia, 
and pain in hip, after exposure, Aug. 9th. 



208 



GONORRHEAL RHEUMATISM. 



10 



11 



12 



Ibid., p. 114. Mr. C, aetat. 
38; full liver 
and subject to 
rheumatism. 



Ibid., p. 115. 



Ibid., p. 118, 



Ibid., p. 120. 



13 Ibid., p. 123. 



14 



Ibid., p. 124, 



Mr. C, aetat. 
30, of spare 
habit and 
leading a se- 
dentary life. 



Patient of 
spare habit 
and good con- 
stitution; had 
always en- 
joyed good 
health ; age 
28. 

Patient 24 
years of age 

and good 
constitution. 



Patient 
25. 



Mr. F., 29 
years of age, 



One. 



One. 



Two. 



One. 



Gonorrhoea followed by inflammation, with effusion 
of knee and swelling of hands. Symptoms were 
improving and urethral discharge had ceased, 
when mild inflammation of the conjunctiva came 
on in both eyes ; this subsided in a few days under 
the use of tepid lotions. 

Within a few years after marriage, had four attacks 
of discharge from the urethra, "without infec- 
tion." The last of the four attacks was attended 
with painful swelling of the foot and enlargement 
of the glands in the groin. Four years afterwards 
(June, 1827) had an acute attack of aquo -capsu- 
litis in left eye, with copious effusion of lymph in 
anterior chamber ; under treatment these symp- 
toms entirely disappeared. 

Sept. 7th, contracted gonorrhoea from impure con- 
nection. Sept. 18th, mild conjunctivitis ensued 
in both eyes; and, Sept. 21st, rheumatism of foot 
and upper extremities, the discharge from the 
urethra still continuing. 

In Feb., 1828, he had severe inflammation of the 
external tunics and iris on both sides ; some stiff- 
ness of joints still remained; no mention of the 
urethral discharge. 

An attack of gonorrhoea was getting better, when 
rheumatism of the joints of foot and of the knee 
appeared, followed in a short time by inflamma- 
tion of the sclerotica and iris in both eyes, which 
left permanent adhesions between the iris and 
anterior capsule. 



1st attack. Patient contracted gonorrhoea, the symp- 
toms of which were very severe. In three weeks, 
both eyes became " red and inflamed, painful and 
acutely sensible to light ; lachrymation and mu- 
cous discharge" (inflammation of the sclerotica 
and iris). No affection of joints mentioned. 

2d attack, occurring 18 months after the preceding. 
As before, a severe attack of gonorrhoea followed 
in a fortnight by an attack of conjunctivitis, which 
disappeared in a few days. About a fortnight 
after, however, the gonorrhoea still continuing, the 
eyes again became inflamed ; the inflammation 
being seated in the "deeper tunics." Soon after 
rheumatism appeared affecting all the joints of the 
body, but particularly the knee. 

Patient continued well for about two years, when he 
had a severe attack of rheumatism without any 
affection of the eyes. 

Patient had had a slight gonorrhoeal discharge for 
some time, when inflammation of the internal 
tunics and iris of both eyes ensued, followed in a 
few days by inflammation of the knee-joint. The 
eyes recovered in a month, the urethritis and 
rheumatism still continued for a year afterwards. 

Five weeks after the commencement of an attack of 
gonorrhoea, had severe pains in the back, sides, 
and lower limbs ; after these had continued a fort- 
night, he had injection of the sclerotic vessels, 
with profuse lachrymation and dimness of vision. 



METASTATIC GONORRHEAL OPHTHALMIA. 



209 



15 



16 



17 



Ibid., p. 127. Mr. L., 29 
years of age. 



Tyrrell, vol. Patient 46 
i. p. 387. years of age 



Ibid., p. 392. 



18 Ibid., p. 394. 

19 Ibid., p. 394, 



20 



21 



Ibid., p. 395, 



Patient 20 
years of age. 

fair com- 
plexion and 

scrofulous 

diathesis. 



Had an attack of gonorrhoea nine years ago, unac- 
companied by any rheumatic affection. Four 
years ago, had gonorrhoea, followed by rheuma- 
tism, which affected particularly the feet. 

A third attack of gonorrhoea, ten months ago, fol- 
lowed in a week by rheumatism in the feet, 
which has continued till the present time ; mean- 
while he has had an attack of sclero-iritis in each 
eye. 



Four. Gonorrhoea; inflammation of several joints with effu- 
sion ; inflammation of conjunctiva and sclerotica 
in both eyes, and in one extending to the iris and 
choroid. Order of sequence of these affections not 
given. Other three attacks similar. 

One. After the acute stage of an attack of gonorrhoea had 
subsided, inflammation of the synovial capsule of 
the knee and of the conjunctiva and sclerotica of 
both eyes. 



One. " Similar to the last case." 

One. Similar to the two previous cases, except that the 
inflammation extended to the iris and choroid of 
one eye. 

Six or |Each attack was preceded by slight gonorrhoea ; no 
inflammation of synovial membranes, but rheu- 
matic pains about shoulders, arms and neck prior 
to disease of eyes ; inflammation of conjunctiva 
and sclerotica, dull aching pain in globe and brow 
aggravated at night, dull condition of iris, irre- 
gular pupil, muscae. 



Vetch, Prac- Patient 25 

tical Treatise years of age. 
on the Dis- 
eases of the 

Eye; London, 

1820, p. 243. 



22 Prof. Graves, 
London Med. 

Gaz., new 

series, vol. i. 

p. 440. 



23 



Sir Astley 
Cooper, Lec- 
tures on the 

Principles 
and Practice 
of Surgery ; 

London, 
1835, p. 482. 



14 



P., aged 35 
years. 



Two, 
a,t fivt 
years' 
inter- 
val. 



Four. 



Three. 



In each attack the subsidence of the gonorrhoea was 
attended by rheumatism of the knee and joints of 
foot, followed by inflammation of the sclerotica 
and iris ; irregular and contracted pupil, synechia, 
opacity of capsule of lens, and impaired vision. 
There was no chemosis or purulent discharge in 
either attack. Swelled testicle present in the first. 

The gonorrhoea in each attack ran its course till the 
discharge and inflammation began to decline, when 
the eyes invariably became inflamed, presenting 
all the symptoms of simple acute conjunctivitis, 
and after a few days the sclerotica and other 
tissues became involved. Again, after the oph- 
thalmia had lasted a few days, one of his joints 
invariably became affected with acute inflamma- 
tion. 

An American gentleman applied to Sir Astley Cooper 
to be treated for gonorrhoea, and told him that in 
two former attacks he had had inflammation in 
the eyes, and rheumatism in the joints. Sir Astley 
cautioned him against allowing any matter from 
the urethra to come in contact with the eye. 
Three days after, the man had "ophthalmia" in 
both eyes, which was cured with great difficulty; 
and in three days more he had rheumatism in 
each knee. (It is evident that the disease of the 
eye in this case was not purulent conjunctivitis.) 



210 



GONOEKHCEAL BHEUMATISM. 



I 
24 



Rollet, An- 
nuaire de la 

Syphilis ; 

annee 1858, 

p. 19. 



25 Ibid., p. 20. 



26 



Brandes, 
Arch. Gen. 

de Med., 
Sept. 1854. 



27 



Same 
author. 



Patient 

24 years, an 

inmate of the 

Venereal 

Hospital at 

Lyon. 

Patient aged 

30; never had 

rheumatism 

before. 



Patient had 
stricture, and 
these several 

attacks were 
probably not 

due to fresh 
contagion. 



One. 



One. 



Two 
at an 
inter- 
val of 
three 
years. 



Five at 
inter 
vals of 
one or 

two 
years 



Inflammation of eyes commenced eight days after 
gonorrhoea; redness of conjunctivae, lachrymation, 
cornea slightly opaque atresia and irregularity 
of pupils, circumorbital pains. Inflammation of 
knee-joint with effusion took place four days after 
the disease of eyes appeared. 

Disease of the eye appeared eight days after urethral 
discharge. Left eye only affected; injection of 
conjunctival vessels ; pupil irregular, iris darker 
than on opposite side ; slight opacity within the 
pupil ; pain in the orbital region. Inflammation 
of joints of knee and foot came on in about seven 
weeks, the disease of urethra and eye still con- 
tinuing. 

1st attack. The day following the appearance of a 
gonorrhoea, patient began to suffer from an " oph- 
thalmia" of both eyes and pain in one shoulder. 
The ophthalmia subsided under treatment. A re- 
lapse taking place, several joints were affected 
with rheumatism, the iris became inflamed, with 
hypopion. 

2d attack. Ophthalmia appeared in five days, and 
rheumatism in eight, after gonorrhoea ; iris in- 
flamed, several joints involved. 

Inflammation of the iris, followed by rheumatism, 
in each attack. 



In all the cases included in this table, the eye disease was pre- 
ceded, attended, or followed by rheumatism. In a majority of the 
attacks the ophthalmia preceded the rheumatism. 

In about two-thirds of the cases of which we have sufficient details 
to enable us to determine the seat of the ophthalmia, the sclerotica 
and iris were chiefly affected; in the remaining third, the conjunctiva. 
In the latter class, it is sometimes noted that there was purulent 
discharge and chemosis ; but the inflammation does not appear to 
have assumed the severity of gonorrhoeal ophthalmia from conta- 
gion, since only one (ISTo. 6) terminated in ulceration of the cornea, 
and most of the cases yielded readily to treatment. 

We may conclude, therefore, that gonorrhoeal rheumatism, like 
rheumatic gout, may attack any of the ocular tunics, though it 
most frequently involves the sclerotica, from which it may extend 
to the conjunctiva, iris, or other tissues. 1 It must be borne in mind 



1 These cases do not confirm Rollet's statement, that gonorrhoeal rheumatic oph- 
thalmia is always a kerato-iritis. 



DIAGNOSIS. 211 

that the vascular connection of all the tissues of the eye is very 
intimate, and that the inflammatory process is never wholly con- 
fined to one portion of the globe. It is highly probable, I think, 
that many cases of gonorrheal rheumatic ophthalmia, which have 
been described as conjunctivitis, have in reality been instances of 
conjunctivo-sclerotitis, in which the injection of the conjunctival 
vessels has masked that of the sclerotica. The orbital and circum- 
orbital pain, which are often mentioned, would indicate this. At the 
same time, it must be confessed, that in some instances the chief seat 
of the disease has been the conjunctiva, and that the presence of 
a muco-purulent discharge and a certain degree of chemosis, have 
rendered these cases readily mistakable for gonorrhoeal ophthalmia 
from contagion. The milder character of the disease, the history 
and habits of the patient, and the existence of rheumatism, are, in 
such instances, the chief elements on which to found a diagnosis. 
When a patient has had an affection of the eyes and joints in 
previous attacks of gonorrhoea, or when gonorrhoeal rheumatism 
coexists with an ophthalmia which does not present the severe 
symptoms of purulent conjunctivitis, there is a strong probability 
that it is of the rheumatic form, even though the conjunctiva appears 
to be chiefly affected. Not unfrequently, also, rheumatic ophthalmia, 
after entirely disappearing from one eye, involves the opposite eye, 
or returns a second time to the one first affected, a course never 
pursued by gonorrhoeal ophthalmia from contagion. 

In by far the larger proportion of cases, however, as shown by 
the above table, the symptoms of gonorrhoeal rheumatic ophthalmia 
are those of sclerotitis, iritis, or kerato-iritis, either separate or com- 
bined. I shall not attempt to describe the characteristic features 
of these different forms, since they are identical with those of the 
same affections arising from other causes. 

I will merely remark that when the iris is involved, it generally 
appears to be so secondarily, and that the inflammation affects it to 
a less extent and more superficially than in other forms of iritis ; 
hence that there is less danger of adhesions to the capsule of the 
lens and of atresia iridis, and that tubercular excrescences are 
probably never seen upon its surface. 

Diagnosis. — The admission of gonorrhoeal rheumatism as a dis- 
tinct disease, is by no means dependent upon the question whether 
it presents any symptoms different from those of ordinary rheuma- 



212 GONORRHEAL RHEUMATISM. 

tism. Inflammation of the epididymis, identical with swelling of the 
testicle attendant upon gonorrhoea, may be excited by other causes; 
and even if no diagnostic signs of the rheumatism caused by ure- 
thritis be admitted, we should still be warranted in using the term 
"gonorrhoeal rheumatism " as indicating the connection between the 
two diseases. 

It is evident, however, that the disease now under consideration 
differs in some respects both from acute rheumatism and rheumatic 
gout, though much more closely allied to the latter than to the 
former. 

It differs from acute rheumatism in the absence or slightly 
marked character of its premonitory symptoms ; in the less degree 
of constitutional disturbance which attends it; in being limited 
to a few joints ; in its predilection for the synovial membranes ; in 
rarely attacking the heart but frequently the eye ; in its persist- 
ency ; and in seldom affecting women. It differs from rheumatic 
gout in the fact that hereditary influences, so far as at present 
proved, have no part in its production ; also in the frequency with 
which it attacks the knee-joint ; in its preference for the male sex, 
and in its rarely leaving any permanent traces of its invasion. 

Whether these points of difference are sufficient or not to con- 
stitute a distinct species of rheumatism, is a question which proba- 
bly cannot be decided with satisfaction to every mind. Even the 
laws of classification in the animal and vegetable kingdoms are as 
yet far from being settled ; much less can it be said that there are 
fixed rules for determining how great a degree of difference will 
justify a distinct species in the natural history of disease. All that 
we can say with regard to gonorrhceal rheumatism, is, that in well- 
marked cases, it presents certain characteristic features sufficient to 
indicate its origin, even when before unknown. In some instances, 
its symptoms resemble those of other forms of rheumatism so 
closely, that we should not be led to suspect its character, unless 
aware that the patient was suffering from gonorrhoea. 

In a given case of this kind, therefore, it may at times be ex- 
tremely difficult to determine whether our patient has an affection 
of the joints dependent upon his urethritis, or whether his rheuma- 
tism is simply a coincidence ; if, however, there be but little con- 
stitutional disturbance ; if only a few joints, and particularly the 
knee, be affected ; if the disease be chiefly confined to the synovial 
membrane — as shown by the articular effusion, and the slight 



NATURE. 213 

degree of heat and redness externally — and if it exhibit but slight 
tendency to migrate from one joint to another, then there can be 
little question that the gonorrhoea and rheumatism bear to each 
other the relation of cause and effect. The probability will be still 
further strengthened, if the patient has never been subject to rheu- 
matism ; or, a fortiori, if he has had it only in conjunction with 
previous attacks of gonorrhoea. 

Nature. — The power of exciting rheumatism, exercised by 
gonorrhoea in certain cases, has often been advanced as an argu- 
ment to prove that the latter disease is a modified form of syphilis; 
and it has been asserted that the rheumatism is due to the absorp- 
tion of a specific poison from the urethra. This idea has probably 
derived additional weight from the supposition that no other 
satisfactory explanation could be given of the connection between 
these two diseases, and before such was found, the theory of a syphi- 
litic or gonorrhea al virus was thought to be the only alternative. 
The question has been asked : If the rheumatism is not produced 
by the absorption of a specific poison, how is it produced ? But 
such a process of reasoning is founded on a gross over-estimate of 
our knowledge of cause and effect in disease. The connection 
between gonorrhoea and rheumatism is only one of many instances, 
in which the link which binds two diseases together escapes us, 
although the union is plain and unquestionable. Who, for instance, 
can account for the intermittent fever which is sometimes occasioned 
by a stricture of the urethra ; or explain the connection between 
chorea and rheumatism — a connection so intimate that a large 
proportion of children who have the one will have the other ; or 
the reason that disease of the supra-renal capsules causes bronzing 
of the skin? And so throughout the etiology of all diseases, if 
for a moment we endeavor to divest our minds of the familiarity 
which daily observation has given to the connection between them 
and the causes which produce them, in how few instances do we 
really understand the mechanism of the process ! 

Facts which occur but rarely, excite wonder; if frequent or 
coinciding with other known phenomena, the mind receives them 
without distrust. Is it then an isolated fact that a local affection, 
entirely destitute of specific properties, is capable of exciting 
rheumatism? By no means. Dr. Fuller, who believes that the 
proximate cause of rheumatism is a poison generated in the sys- 



214 GONORRHEAL RHEUMATISM. 

tern (not absorbed from without) as the result of faulty metamor- 
phic action, thus speaks of the influence of local disease : • ■ One 
part of the animal economy hinges so closely on the other, that 
local mischief occasions general disturbance, and under certain 
circumstances appears to induce a state of system favorable to the 
generation of rheumatic poison; a state of system arising, be it 
observed, not as a direct and immediate consequence of suspended 
secretion, but as a sequel of perverted function gradually taken on 
by the system generally, in consequence of imperfect or morbid 
local action. Excessive venery and long-continued debauchery 
are frequently productive of rheumatism, and so is immoderately 
protracted lactation. The phenomena of gonorrhoea afford an ad- 
mirable example of how local diseases may gradually give rise to 
general derangement of the system, and so to the production of the 
peccant matter of rheumatism." 1 This connection between local 
diseases in general and inflammation of the joints is also fully 
recognized by other observers ; it need not therefore surprise us, 
nor is there any necessity to suppose the absorption of a specific 
poison, when we find that rheumatism can be excited by inflamma- 
tion of the urethra. 

Moreover, evidence is not wanting to show that the phenomena 
of gonorrhoeal rheumatism cannot be explained on the ground 
that the syphilitic or any other specific poison has been taken into 
the system from without. In order not to extend this subject to 
too great length, I will merely enumerate the chief points of this 
evidence. 

1. If gonorrhoeal rheumatism were due to the absorption of a 
virus, it ought to be a very frequent disease, considering the multi- 
tude of patients affected with gonorrhoea; it is, however, quite 
infrequent. 

2. On the same supposition, it ought to run a regular and definite 
course, like specific diseases in general. 

3. One attack, also, should afford immunity from, or at least 
partial protection against subsequent attacks in the same person. 

4. No evidence of the absorption of a virus is found in an ex- 
amination of the lymphatic vessels or ganglia in gonorrhoea, as in 
syphilis. Even in cases of gonorrhoeal rheumatism, the absorbents 
in the neighborhood of the genital organs retain their normal con- 
dition. 

1 Fuller on Rheumatism, p. 35. 



TREATMENT. 215 

5. Gonorrhoeal rheumatism has repeatedly been known to occur 
in connection with urethritis which had been excited by the use of 
bougies, or by intercourse with women during the menstrual period. 
If it can thus be caused by a simple urethritis, why is it ever ne- 
cessary to attribute it to a "virulent gonorrhoea?" 

6. None of the known symptoms of constitutional syphilis bear 
any more than the slightest resemblance to gonorrhoeal rheumatism. 

Treatment. — It is evident that we cannot deduce the treatment 
of gonorrhoeal rheumatism from that of acute rheumatism, as has 
sometimes been done by writers on this subject ; nor, again, en- 
tirely from that of rheumatic gout, although here, it is not im- 
probable that a somewhat similar line of treatment may be found 
applicable. But if we recognize a special cause and certain 
peculiarities in the symptoms of gonorrhoeal rheumatism, the 
treatment of this disease demands investigation independent of 
any preconceived notions derived from our experience with 
kindred affections. 

The amount of constitutional disturbance attending the com- 
mencement of an attack of gonorrhoeal rheumatism is rarely 
sufficient to require active antiphlogistic measures. The adminis- 
tration of an emetic, or a free purge, as from five to ten grains of 
calomel, followed by castor oil or Epsom salts, is commonly suffi- 
cient to allay the febrile excitement, and has the additional advan- 
tage of correcting the condition of the digestive organs which are 
usually at fault. The patient should be kept quiet, and his diet be 
proportioned to the severity of the febrile action. The chief means 
of combating the local inflammation is to be found in the abstrac- 
tion of blood from the neighborhood of the joint. Cups or leeches 
should be applied, and repeated as often as the case requires. They 
afford marked relief to the pain, often arrest the progress of the 
disease, and hasten its resolution. 

After the more acute symptoms have been subdued, or even at 
the outset, when the disease is from the first of a subacute character, 
the greatest benefit will be derived from blisters. These are 
especially applicable, when a large joint, like the knee, is attacked, 
and when an effusion within the capsule is a prominent symptom. 
The vesicated surface may be dressed with simple cerate with the 
addition of five grains of morphine to each ounce, and so soon as 
the surface heals a fresh blister may be applied. If strangury 



216 GONOKEHCEAL EHEUMATISM. 

ensue, the daily application of strong tincture of iodine may be 
substituted for the unguentum lyttse. Yelpeau recommends that 
the joint be kept constantly smeared with mercurial ointment, to 
which some preparation of opium has been added. 

Eicord and some other writers advise the internal administration 
of colchicum, alkalies, and the salts of potash, as in rheumatism 
dependent upon other causes, but the reports of cases in which 
these remedies have been employed are far from proving their 
efficacy. Diuretics of any kind are objectionable, since they tend 
to keep up the urethral discharge. The occasional use of an emetic 
or purge has in the hands of several surgeons been found to be of 
decided advantage. Eollet speaks highly of vapor baths. Copaiba 
and cubebs have no effect upon the rheumatism, and can only be 
required for the urethritis, which, in most cases, however, is more 
satisfactorily treated by local measures. 

Meanwhile, the treatment of the urethral discharge on which the 
rheumatism depends, should not be neglected. Unless this be 
entirely arrested, there is always danger of a relapse. In many of 
the cases reported, the rheumatism has repeatedly returned at 
intervals of several months, so long as the exciting cause continued. 
The measures already recommended for the treatment of gonorrhoea 
and gleet should, therefore, be actively employed, at the same time 
that attention is paid to the affection of the joints. 

When gonorrhoeal rheumatism occurs in persons of broken-down 
constitution, or when the general health becomes impaired by the 
continuance of the urethral and articular disease, it is necessary to 
resort to hygienic measures, and frequently to the administration of 
tonics, as preparations of iron, iodine, cod-liver oil, bark, etc. These 
remedies, together with fresh air and good diet, should by no means 
be neglected, as soon as the patient is found to be debilitated. 

A very efficacious method of treating the swelling which often 
remains after the acute symptoms have subsided, is by means of 
strips of adhesive plaster so applied as to exercise compression 
and at the same time render the joint immovable. Supposing the 
knee to be affected, the limb should be bandaged from the toes up 
to the point where the plaster is to commence, or just below the 
swelling. The strips should be of about two fingers' breadth, and 
each one, first passed behind the limb, be brought round in front, 
and its ends made to cross like the letter X. One strip after 
another is applied, each overlapping the preceding for about one- 



TREATMENT. 217 

third its width, until the whole joint is covered, when four or five 
additional layers are superposed in the same manner, in order to 
insure a sufficient degree of stiffness, and the whole enveloped in a 
bandage. I can speak very decidedly of the good effects of this 
application in this and other chronic affections of the joints. 

"When the eye becomes inflamed, local depletion by means of 
leeches or cups to the temples should be resorted to. If the con- 
junctiva be involved, the strictest cleanliness should be maintained 
by frequent bathing with tepid water. Astringent collyria are less 
frequently called for than in conjunctivitis independent of any 
rheumatic taint ; if used, their effect should be carefully watched, 
and, if they fail to afford relief, they should be omitted. When the 
iris is implicated, the pupil must be dilated by atropine, and mercu- 
rials administered as in other forms of iritis. 



218 VEGETATIONS, 



CHAPTER XII. 

VEGETATIONS. 

Vegetation's are papillary growths springing from the skin or 
mucous membrane chiefly in the neighborhood of the genital organs, 
and identical in their nature with the warts which are so common 
upon the hands. They are not, strictly speaking, venereal, since 
they are not necessarily connected with either of the diseases 
originating in sexual intercourse. It is true that they are most 
frequently observed in men and women who have been affected 
with gonorrhoea, balanitis, or chancres ; but this is simply because 
the skin or mucous membrane has for a time been moistened 
with an acrid secretion which has favored the abnormal develop- 
ment of its papillae. They are found in young children, with 
regard to whose purity there can be no suspicion; and also in 
adults who have never suffered from any venereal disease whatso- 
ever. Again, they are not unfrequently met with during pregnancy ; 
the increased secretion from the vagina and the determination of 
the blood to the pelvis at this time being highly favorable to their 
development. 

The importance of these growths has been very much exag- 
gerated. Thus, they have been regarded as syphilitic, and as an 
indication of the necessity of specific remedies ; and this, too, in 
spite of the generally recognized fact that mercury has no effect 
whatever in their removal. Their only connection with primary 
or secondary syphilis is when they spring from the surface of a 
chancre, mucous patch, or other constitutional lesion, upon which 
they are a merely accidental formation. The sore which serves as 
their base may require a mercurial course, but the superadded 
vegetation in itself presents no such indication. 

Again, it is often said that they are contagious; and some 
semblance of truth for this supposition has been found in the fact 
that when situated upon one of two opposed surfaces, as the labia 



VEGETATIONS. 219 

or upper and inner parts of the thighs, similar growths not unfre- 
quently spring np upon the opposite; and somewhat doubtful 
cases have been reported in which, as alleged, vegetations have 
appeared upon men after connection with women who were simi- 
larly affected. But, such instances are readily explained on the 
ground that the acrid secretion from vegetations, when applied to 
neighboring parts, and, possibly, when transferred to another indi- 
vidual, acts in the manner already explained, and gives rise to 
others. The very fact that their supposed contagion takes place 
upon the person affected, is sufficient to prove that they are not 
dependent upon the virus of true syphilis, the lesions of which are 
not auto-inoculable ; and there is no reason whatever for ascribing 
them to the poison of the chancroid. Moreover, they present the 
same aspect, follow the same course, and are amenable to the same 
treatment^ when occurring in young children and pregnant women 
who are otherwise healthy, as in persons affected with venereal 
diseases. 

Several varieties of vegetations have been admitted, especially 
by the French, founded upon their resemblance to various objects 
in nature. Thus, Alibert, who believed that vegetations were 
syphilitic, admitted them as one of three principal forms of the 
syphilodermata ; and divided them into six varieties : " La syphilis 
vege'tante framboisee;" "en choux fleurs;" "en cretes;" "en poi- 
reaux;" and "en vermes;" to which he added the truly syphilitic 
lesion, mucous patches, under the head of " condylomes." 

No useful purpose, however, is attained by this classification, 
which serves only to confuse the mind ; since the form of vegeta- 
tions is solely dependent upon accidental circumstances, as their 
position and the pressure of neighboring parts. It is sufficient to 
know that they are sometimes flat and but little elevated above the 
surface ; while at others they are attached by means of a pedicle of 
variable diameter ; and that they are chiefly developed in whatever 
direction they meet with the least resistance. When exposed to 
the air they are often dry and hard ; when protected by an opposed 
surface, they are soft and smeared with a highly offensive secretion. 

Their microscopical appearances are thus described by Lebert : 
" A feeble power shows their internal vascular structure and numer- 
ous sebaceous follicles about their base. With a high power, the 
papillae appear to be composed of an outer rind consisting of con- 
centric layers, and of an internal substance ; the two differ from 



220 VEGETATIONS. 

each other only in density; for, besides their vascular element, they 
consist only of epidermic cells. In the outer layers, these cells are 
more densely packed and present a longer and narrower outline, 
which, at first sight, gives them a fibrous appearance. The internal 
portion is also composed of epidermic cells in close juxtaposition, 
but round and finely dotted on their surface. Yegetations are 
nothing else than a development of the papillae of the epidermis, 
and, in their anatomical composition, do not differ much from certain 
papilliform warts." 

Yegetations are most frequently met with upon the internal sur- 
face of the prepuce directly back of the furrow at the base of the 
glans ; they are also found upon the margin of the meatus, or within 
this orifice upon the walls of the fossa navicularis ; upon the vulva 
in women, and especially in the neighborhood of the carunculae 
myrtiformes ; and, in both sexes, around the anus, upon the tongue, 
velum palati, and even within the larynx. 

Tkeatment. — The treatment of vegetations consists simply in 
their removal by the knife, caustic, or ligature, and the destruction 
of the base from which they spring. "With the vegetations upon 
the internal surface of the prepuce, I have found it most convenient 
to touch them with fuming nitric acid, and repeat the application 
upon the fall of the eschar as often as may be necessary; or, when 
the growth is prominent and pedunculated, it may be snipped off 
with scissors and the base thoroughly cauterized, although, when 
cutting instruments are used, the hemorrhage is sometimes a little 
troublesome. As soon as the tenderness produced by the applica- 
tion of caustic has subsided, it is desirable to keep the glans un- 
covered in order to harden the internal layer of the prepuce by 
exposure to the air and friction ; and, unless the preputial orifice is 
very narrow, this may generally be accomplished by wearing for a 
few days a narrow bandage round the penis posterior to the glans. 
Special attention should also be paid to removing any collection of 
the smegma prseputii, and keeping the parts perfectly clean. 

The nitric acid acts so favorably, that I have seldom resorted to 
other caustics, with the exception of chromic acid, which has come 
into favor within a few years. A solution of this acid (one hun- 
dred grains to the ounce of water) is a powerful escharotic, and is 
especially useful in those obstinate cases in which the vegetation 
repeatedly returns after removal; but it should be applied with 



TREATMENT. 221 

caution, simply moistening the surface of the morbid growth and 
sparing the healthy tissues in the neighborhood, or otherwise it is 
apt to induce severe pain and inflammation. 

I have sometimes employed a mixture of equal parts of dilute 
muriatic acid and tincture of the chloride of iron, which is one of 
the best escharotics for warts upon the hands in children. 

Vegetations about the vulva may be treated in the same way as 
those upon the prepuce. When situated around the margin of the 
anus, they are generally of considerable size, and require to be snip- 
ped off with scissors before the application of acid to the base. 

Vegetations during pregnancy may appear at quite an early 
period ; they grow very rapidly, and often attain an immense size. 
I have seen a mass as large as a man's arm, extending from the 
mons veneris to the sacrum, and surrounding the vulva and anus. 
During gestation no operative procedure is admissible; but the 
pain, itching, and offensive odor may be palliated by careful atten- 
tion to cleanliness and lotions of diluted Labarraque's solution, or 
the application of some astringent powder, as equal parts of savin 
and burnt alum. After delivery, they often disappear spontaneously 
or may be removed by the knife or caustic ; but when the mass is 
very large, only a portion should be attacked at a time. 

Vegetations situated upon a chancre or mucous patch cannot 
always be distinguished from those upon the sound integument ; 
but the history of the case, and, especially, the coexisting symp- 
toms, will determine whether mercury is required to combat syphi- 
litic infection of the general system. 



222 STRICTURE OF THE URETHRA. 



CHAPTER XIII. 

STRICTURE OF THE URETHRA. 

Having considered the complications of gonorrhoea, it remains 
to speak of one of the most frequent and important results of the 
same disease, urethral stricture. 

ANATOMICAL CONSIDERATIONS. 

An acquaintance with the anatomy of the urethra — including the 
character of its lining membrane, the fibrous, muscular, elastic, and 
erectile tissues which surround it, its dimensions and direction — is 
essential to a proper appreciation of the pathology of stricture and 
the skilful execution of operative procedures requisite in its treat- 
ment. 

The male urethra is naturally divided into three portions, viz., 
the prostatic, membranous, and spongy. 

The prostatic urethra is the portion included in the prostate 
gland, and generally, but not always, traverses this body at the 
union of its middle and upper thirds. Its length in the adult is 
about one inch and a quarter ; its posterior boundary is a promi- 
nence of the mucous membrane, called the uvula vesicae ; its cavity 
is fusiform, largest in the centre and somewhat contracted towards 
either extremity. Upon its floor, a short distance in front of the 
uvula, is an abrupt elevation of the mucous membrane and subja- 
cent tissue, which forms a ridge three-fourths of an inch in length, 
and which gradually subsides as it approaches the membranous 
urethra. This prominence is known as the veru montanum, crista 
urethrse, or caput gallinaginis. It contains erectile tissue, connected 
with that of the corpus spongiosum, and is adapted to assist in the 
closure of the urethra at this point, and prevent the passage back- 
wards of the semen during coitus. Directly in front of the summit 
of the veru montanum, is a small sac or pouch, three or four lines 



ANATOMICAL CONSIDERATIONS, 



223 



in depth, which is called the " sinus pocularis." and also, from its 

probable homology to the womb, the "uterus masculinus." 1 The 

ejaculatory ducts traverse the walls of this cavity and open upon 

its margin. On each side of the veru is a depression called the 

"prostatic sinus," in which are 

found the orifices of the prostatic Fi S- 4 - 

ducts, from twenty to thirty in 

number. 

The membranous urethra ex- 
tends from the apex of the pros- 
tate to the bulb, and is nearly or 
wholly included within the two 
layers of the deep perineal fascia. 
It is about three-fourths of an 
inch in length on its upper, but 
is shorter on its lower surface, 
owing to the encroachment of 
the bulb upon the latter. It is 
narrower than any other part of 
the urethra, except the meatus, 
and in consequence of the greater 
development and number of mus- 
cular tissues surrounding it, pos- 
sesses in a higher degree the 
power of contraction. This cha- 
racteristic has led some authors 
to give it the name of the " mus- 
cular region" of the urethra. 

The spongy urethra, inclosed in 
the erectile tissue of the corpus 
spongiosum, varies in length ac- 
cording to the degree of turges- 
cence of the penis ; in a state of 
relaxation, it usually measures 
about five inches; during: erec- 

° Meatus 

tion, it may attam seven or eight. 

ri-n • j* n ,i • The bladder and urethra laid open. 

The posterior portion of this fromabove . (After gray.) 



Cou-pcr's G7and. 



Ortf-.-e/f if JucU. 
o/Cowpers Cilands 




Seen 



1 The most recent philosophical anatomists confirm the analogy between the 
prostatic vesicle and the uterus. For an able resume of this subject, see Simpson, 
Obstetric Memoirs and Contributions, vol. ii. p. 294. Philadelphia, 1856. 



224 STRICTURE OF THE URETHRA. 

region is somewhat dilated, especially on its inferior aspect, and 
has received the name of "the sinus of the bulb." The term 
"bulbous portion" is also applied to the posterior inch of the 
spongy urethra. The ducts of Cowper's glands open near its 
centre. Besides being somewhat dilated, the sinus of the bulb is 
extremely dilatable. This may be shown by two casts of the 
urethra in fusible metal, the one taken while the canal is simply 
filled, the other while it is forcibly distended by the metal. The 
difference in the size of the part corresponding to the bulb will 
exhibit the dilatability of which it is susceptible. Wood-cuts of 
two casts thus taken may be found in the London Lancet (Am. ed.), 
Aug. 1851, p. 97. Anterior to its sinus, the spongy portion main- 
tains a nearly uniform diameter until within about an inch of the 
meatus, where it again enlarges and forms the " fossa navicularis." 
Lastly, the external orifice or " meatus" is a narrow vertical slit, 
which is the most contracted part of the whole canal. In some 
rare instances, however, the smallest diameter is found about a 
quarter of an inch within the meatus, where it can of course be 
seen. 

The mucous membrane lining these various regions is continuous 
posteriorly with that of the bladder, and anteriorly with the covering 
of the glans penis. It is very delicate in its structure, and abund- 
antly supplied with bloodvessels and nerves, which render it highly 
vascular and sensitive. Numerous glands ("glands of Littre"), 
racemose in their structure, 1 are found in the spongy and mem- 
branous, and mucous follicles in the prostatic region, the secretion 
from all of which constantly lubricates the passage. Fossae or 
lacunas of the mucous membrane, apparently destitute of glandular 
structure, are also found upon the upper, and more numerously 
upon the lower surface of the urethra. They may sometimes be 
traced for nearly half an inch beneath the lining membrane, and 
their mouths are commonly directed forwards. One, larger than the 
rest, and called the " lacuna magna," is situated on the upper aspect 
of the canal, from half an inch to an inch posterior to the meatus. 
These lacunas, especially when dilated by long-continued inflamma- 
tion, may obstruct the passage of a sound and lead to the formation 
of false passages. The urethral mucous membrane is covered with 

1 Kollikek, Manual of Human Histology, published by the Sydenham Soc, vol. 
ii. p. 236. 






SPONGY URETHRA. 



225 



Fig. 5. 




the cylindrical form of epithelium. Except in trie prostatic region, 
this membrane is arranged in longitudinal folds, which are generally 
in contact, and close the canal, the latter 
appearing on a transverse section of the 
penis as a mere star or slit. The fact 
that the urethra, under ordinary circum- 
stances, is collapsed, and cannot be said 
to constitute a tube except when dis- 
tended, is of importance with reference to 
the method of using injections in gonor- 
rhoea. Unless the meatus be compressed, 
it is hardly possible that the urethral 
folds should be thoroughly opened, so that 
the fluid may come in contact with the 
whole mucous surface and the mouths of 
its lacunae ; and unless this be accomplished, 
injections can be of but little avail. 

According to Mr. Thompson, the rugae 
of the mucous membrane " appear to be 
connected with the existence of numerous 
long and slender bands of fibrous tissue, 
which are seen lying immediately beneath 

the mucous membrane, for the most part in a longitudinal direction. 
In the bulbous and membranous portions they are extremely 
delicate, constituting these the weakest parts of the urethral wall, a 
fact worthy of remembrance in connection with the use of instru- 
ments." 1 In the bulbous region the danger of doing violence is 
increased by the dilatability of the passage, and by the presence of 
the firm anterior layer of perineal fascia just beyond it. 

The dimensions and direction of the urethra, taken as a whole, 
will be better appreciated after considering other tissues which 
surround it. 

The urethra is invested by " unstriped, organic, or involuntary" 
muscular fibres, one layer of which is separated from the mucous 
membrane throughout its whole course, merely by elastic and 
areolar tissue ; while in the prostatic and spongy regions, a second 
layer is found external to the prostate and corpus spongiosum ; the 



A. Superior surface of urethra. 
B. Fossa navicularis. O. Probe 
inserted iu D, the lacuna magna. 
(After Phillips.) 



1 Pathology and Treatment of Stricture of the Urethra, 2d ed., London, 1858, p. 
12. I am greatly indebted to this unrivalled monograph for much that is contained 
in the present chapter upon stricture. 
15 



226 STRICTURE OF THE URETHRA. 

two being united in the membranous region. These fibres were 
first noticed by Kolliker, 1 in 1848, and afterwards more fully 
described by Mr. Hancock. The first series of fibres above men- 
tioned is continuous posteriorly with the inner muscular layer of the 
bladder, while "the outer layer of the muscular coat of the bladder 
passes forwards on the outside of the prostate gland, to assist in 
forming the organic muscular covering of the membranous portion 
of the urethra ; whilst superiorly, or on the upper surface of the 
gland, these external longitudinal fibres are arranged in two or 
more bundles, which are attached to the pubes near its symphysis. 
From the front of the prostate the conjoined layer of muscular fibres 
passes forwards to the bulb, investing the membranous portion of 
the urethra, covered by, but distinct from the common muscles of 
the part, the latter being inorganic, voluntary, or striated ; these 
being organic and nucleated. Arrived, however, at the bulb, these 
two layers again part company, and extend forwards through the 
whole length of the spongy portion of the urethra, the internal 
layer running between the corpus spongiosum itself and the urethra, 
but separated from the latter by areolar tissue ; the external lying 
on the outside of the corpus spongiosum, separating the proper 
spongy tissue from its fibrous investment. Upon reaching the 
anterior extremity of the urethra, these two layers again unite, and 
form a circular body or band of organic muscular fibres, constituting 
that peculiar structure usually denominated ' the lips of the urethra,' 
and which had previously been considered by Mr. Guthrie as 
surrounded by a peculiar dense structure, analogous to that which 
forms the edge of the eyelid, and which, he believed, was requisite 
to maintain the patency of the opening ; so that not only have we 
the urethra supplied by a coat of organic or involuntary muscular 
fibre, but the spongy body itself lies between its two layers of 
involuntary muscle; an arrangement, doubtless, of very great 
importance, in relation to the due performance of the functions of 
the part." 2 

The demonstration of this continuous layer of muscular tissue 
surrounding the whole course of the urethra, is of the highest 
importance, both with reference to the treatment of stricture and 
the influence which muscular spasm may have in its production. 

1 Beitrage ziir Kenntniss der glatten Muskeln, Zeitschrift fur Wissen, Leipzic, 
1848, Band i. p. 67. 

2 Hancock, Strictures of the Urethra, London, 1852, p. 15. 



CORPUS SPONGIOSUM. 



227 



Involuntary muscular fibre also enters largely into the compo- 
sition of the prostate gland, of which it is said to constitute no less 
than two-thirds, and of the laminae or "trabecular" of the corpus 
spongiosum ; and although its primary function may be to evacuate 
the secretion of the glandular structure of the prostate on the one 
hand, and, on the other, blood which has served the purposes of erec- 
tion, yet it can scarcely be doubted that it may also act as a sphincter 
and compress the urethra in the prostatic and spongy regions. 1 

The corpus spongiosum is dilated at its posterior extremity where 
it forms the bulb ; and since the urethra, leaving the membranous 
region, enters this portion nearer its upper than its lower surface, 
the larger part of the erectile tissue at this point is found below the 
canal. The corpus spongiosum terminates anteriorly in an expan- 
sion, called the " glans penis ;" while a thin layer of erectile tissue 
is continued backwards around the membranous portion of the 
urethra and extends into the veru montanum of the prostate. 

Fig. 6. 




The accompanying diagram, drawn by Mr. Thompson from a 
dissection upon the dead body, admirably exhibits the depth and 
position of the bulb, and its relations to the rectum ; a matter of 
no small importance with reference to operations upon this part. 

The corpus spongiosum consists of a vast number of venous 



1 Thompson, op. cit., p. 44. 



228 



STRICTURE OF THE URETHRA. 



sinuses, communicating with each other in all directions. Its great 
vascularity explains the hemorrhage which is liable to ensue, when 
the spongy, and also the membranous, portion of the urethra is 
divided by the knife of the surgeon or accidentally wounded. 
This occurrence, however, is less likely to take place, when an 
incision is confined to the mesial line ; either in consequence of the 
fibrous partition which separates the two lateral portions of the 
vascular tissue at this point, or, as suggested by Mr. Thompson, 
because the two branches of the pudic artery, which lie one on 
either side, are thus avoided. 

The corpora cavernosa are two in number. Arising in front of the 
tuber ischii, and intimately united to the periosteum covering the 
rami of the ischium and pubis, the two unite in front of the sym- 
physis, to which they are connected by the suspensory ligament, 
and are continued forwards as far as the corona glandis, where their 
common extremity is capped by the expansion of the corpus spon- 
giosum forming the glans. The vascular connection between these 
bodies is free, though little, if any, exists between them and the 
corpus spongiosum, which lies in a groove upon their under surface. 

Deep Perineal Fascia. — The triangular space, seen in the bony 
pelvis to intervene between the pubic and ischiatic rami, is occupied 

Fig. 7. 




], 1, 1. Flaps of the divided superficial fascia. 2. Anterior layer of deep perineal fascia. 3. Ure- 
thral opening. 4. Position of Cowpers glands behind anterior layer of deep fascia. 

by a tense, fibrous septum, constituting one of the chief supports 
of the pelvic viscera above, and known by the various names of 



DEEP PERINEAL FASCIA. 



229 



"deep perineal fascia/' "triangular ligament of the urethra/' 
"Camper's ligament/' "middle perineal fascia," "ano-pubic aponeu- 
rosis," etc. This septum is composed of two layers, separated by 



Fig. 8. 




(After Gray.) 

an interval in which are found the membranous portion of the 
urethra, which necessarily passes through the deep perineal fascia 
to arrive at the surface, the compressor urethr^e muscle, Cowper's 
glands and ducts, the arteries of the bulb, and the dorsal vein, 
nerve, and artery of the penis. We might familiarly liken this 
septum to a double window, through which a funnel, representing 
the urethra, passes ; in which case the portion of the funnel con- 
tained between the sashes would correspond to the membranous 
region. 

At their apex, the two layers of the deep perineal fascia are thin 
and firmly attached to the sub -pubic ligament and pubic bones ; 



230 



STRICTURE OF THE URETHRA. 



they then pass downwards and backwards, and are stretched be- 
tween the pubic and ischiatic rami. The space between them, 
containing the important parts already mentioned, is from half to 




Antericr L aye r of 
Deep Perineal, Fascia removed' 
Shewing, 

COMPRESSOR URETHR/E 

Internal Pudic ArtV. 
Arty cf the Bulk 
Corvjur's Gland 



ml hImih = — "*" ~ 



(After Gray.) 



three-fourths of an inch in depth. The vena dorsalis penis pierces 
the fascia half an inch, and the urethra usually at about an inch 
below the symphysis; but, according to measurements made by 
Mr. Thompson, the latter distance may vary from seven-eighths to 
an inch and a quarter ; a difference of some importance as affecting 
the sub-pubic curve of the urethra. From the urethral opening 
two processes are sent off, one anteriorly to inclose the bulb, and the 
other posteriorly to become continuous with the fibrous capsule 
which surrounds the prostate gland. The inferior margin, or base, 
of the deep perineal fascia is directed towards the rectum, and sends 
off a thin fascia which covers the inferior surface of the levator 
ani muscle ; its anterior layer winds round the transversus perinei, 
and, thus doubled on itself, becomes continuous with the superficial 
perineal fascia. 



SUPERFICIAL PERINEAL FASCIA. 



231 



Superficial Perineal Fascia. — Strictly speaking, there are two 
layers of this fascia, the superficial and deep. The former consists 
of cellulo-adipose tissue, belonging to the general integument of 
the body. The latter is aponeurotic in its structure, and is chiefly 
important in its relation to the present subject. In accordance with 
frequent usage, it alone is intended by the term " superficial fascia 
of the perineum." This fibrous structure corresponds in its general 
direction with the deep perineal fascia just described, but is situated 
upon a more external plane ; behind the transversus perinei muscle 
it is continuous with the anterior layer of the latter fascia ; at the 
sides, it is attached to the rami of the pubic and ischiatic bones, 

Fig. 10. 




(After Gray.) 



while in front it joins the dartos of the scrotum, the sheath of the 
penis, and the abdominal fascia. It also sends off processes which 
invest the transversus perinei and the muscles about the root of 
the penis. 



232 



STRICTURE OF THE URETHRA. 



The relations of the superficial fascia to the penis have been 
more fully described than elsewhere, in the first volume of the 
Transactions of the American Medical Association, by Dr. Gurdon 

Fig. 11. 






GtT Sacro -Seiaii 




Superficial Perineal Artery 
Superficict I Peri nenl Ner ve 
Internal Pudic Nerve 
Internal Pudic Arte ry 



(After Gray.) 

Buck, of New York. As this paper is not generally accessible, 
and deserves a much wider circulation than it has received, I shall 
quote the greater part of it. 

"The anatomical structure in question consists of a distinct 
membranous sheath investing the penis in the manner to be de- 
scribed, and forming a continuation of the suspensory ligament 
above, and of the perineal fascia below, and will be best understood 
by a description of the mode of dissecting it. 

" The penis and scrotum are to be circumscribed by an incision 
at the distance of three fingers' breadth all around, and crossing 
the perineum at the anterior margin of the sphincter. 

"The dissection of the skin and subjacent cellular and adipose 
tissues is to be made towards the penis, on the level of the fascia 



SUPERFICIAL PERINEAL FASCIA. 233 

lata laterally, and of the perineal fascia posteriorly, and carefully 
continued to the body of the penis, as far as the corona glandis. 
By this means, the penis, as well as the suspensory ligament, is 
denuded of its loose movable investments. 

"An incision is then to be made along the dorsum of the penis, 
exactly in the median line, splitting through the suspensory liga- 
ment, and extending forward to the corona, between the dorsal 
vessels and nerves that run parallel on either side. The adhesions 
of the sheath along the dorsum are firm, and require careful dis- 
section ; the bloodvessels and nerves being raised with it, serve as 
a guide to show the line of adhesion. 

" The dissection being prosecuted laterally as well as inferior ly 
and at the extremity, the entire corpus cavernosum is enucleated, 
the muscles of the perineum being raised with the sheath. It is 
now clearly seen that the suspensory ligament from above, and 
the perineal fascia from below and laterally, form one continuous 
membrane with the sheath, inclosing the corpus cavernosum in its 
cavity, and embracing the corpus spongiosum urethras between 
two layers, one of which passes above, and the other below it. 
The excavated base of the glans adheres inseparably to the outer 
surface of the sheath, while, by means of its inner surface, it caps 
the summit of the corpus cavernosum. 

" Its adhesions are most firm at the extremity of the corpus caver- 
nosum, along its dorsal surface, and at the insertions of the erector 
and accelerator muscles. It is thickest around the corona, along 
the dorsal surface, and where it forms the suspensory ligament. 
Zones of vessels run at regular intervals in the direction of the 
circumference of the penis, from the dorsal trunks to the corpus 
spongiosum, between the layers of the sheath. The cavity formed 
by the sheath, and occupied by the corpus cavernosum, is limited 
posteriorly by the triangular ligament (deep perineal fascia). 1 

" That portion which covers the perineal muscles, and has been 
described by authors under the names of the superficial fascia of 
the perineum, inferior fascia and ano-penic fascia, arises laterally 
from the ascending rami of the ischium, and descending of the 
pubis, as far forward as the inferior edge of the symphysis, where 

1 It would thus appear that the process of the anterior layer of the deep perineal 
fascia which is prolonged upon the bulb finally unites with the superficial fascia ; 
and it is so stated by Velpeau, "Traite complet d'Anatomie Chirurgicale," Paris, 
1S37, tome second, p. 216. 



234 STRICTURE OF THE URETHRA. 

the two layers meet and form the suspensory ligament. Posteriorly, 
it is continued over the transverse muscle, and folding around its 
edges is prolonged upwards into the ischio-rectal fossa. 

"It also sends off from its upper surface membranous septa 
between the accelerator muscles in the middle, and the erectors on 
either side, to join the triangular ligament, and thus forms three 
distinct and independent sheaths that are confounded anteriorly 
with the common sheath investing the corpus cavernosum." 

M. Jarjavay has more recently confirmed Dr. Buck's observations, 
and gives full credit to the "chirurgien de l'Amerique" for the 
originality of his discovery. 1 

Eichet, 2 while agreeing with Dr. Buck in the main, differs from 
him in some particulars. He states that the posterior portion of 
this fascia is quite loose and areolar upon the dorsum, where it 
cannot be distinguished from that covering the pubes; and that 
thus a communication is opened by which infiltrations of urine 
may gain the sub-integumental cellular tissue of the penis and 
abdomen without perforating the fascia. 

The spaces intervening between the fasciae now described may 
be said to constitute natural reservoirs, to which infiltrations of 
urine and collections of matter, consequent upon rupture of the 
urethra or inflammation in its neighborhood, are chiefly confined ; 
this being true at the outset of such effusions, and possibly so 
throughout their whole course; although in many instances the 
aponeurotic wall is eventually ruptured, or opened by a process of 
ulceration, when a more extensive diffusion of the contents takes 
place. The practical deductions from the direction and connection 
of these fascial planes are therefore of great importance. They 
may be briefly stated as follows : — 

Urine extra vasated in the membranous or prostatic region, either 
advances towards the pelvic cavity through the fibrous sheath in- 
closing the prostate, or reaches the triangular space by the side of 
the rectum called the ischio-rectal fossa ; in the latter situation, it is 
still, in most instances, deeply situated in the substance of the peri- 
neum ; if it gain the surface it may extend around the union of the 
deep and superficial fascia, and be found in the cellulo-adipose 
tissue external to the last named fascia. 

1 Jakjavay, Traits d'Anatomie Cliirurgicale, Paris, 1854, tome second, p. 576. 

2 Ricuet, Traite d'Anatomie Medico-cliirurgicale, 2d ed., Paris, 1860. 






VOLUNTAKY MUSCLES. 235 

The superficial and the anterior layer of the deep perineal fascia, 
united behind the transversus perinei and attached on each side to 
the ischiatic and pubic rami, form a pouch with its outlet looking 
forwards and upwards, where purulent or urinary abscesses may 
form in consequence of rupture of the urethra anterior to the trian- 
gular ligament, and from which they can only extend into the 
scrotum or over the abdomen, the close attachment of the abdominal 
fascia to Poupart's ligament obstructing their passage down the 
thighs; occasionally, however, the matter breaks through this 
barrier, and has been known to descend nearly to the knee. 

The presence of urine in the pouch just mentioned, is, however, 
for the most part secondary ; when first extravasated anterior to the 
deep perineal fascia, it is confined within the aponeurotic structure 
described by Dr. Buck, where it may be felt as a firm, hard swell- 
ing situated beneath the superficial cellular tissue, which retains its 
natural suppleness and mobility. "Left to itself, the swelling some- 
times gradually approaches the surface by appropriating to itself 
by adhesive inflammation the successive layers of cellular tissue 
covering it, and at length evacuating its contents externally through 
an ulcerated opening. This, however, is not uniformly the case. 
It often happens that the ulcerative process within the abscess goes 
on in advance of the adhesive and conservative process on the out- 
side and opens a communication into the loose cellular tissue cover- 
ing it, the consequence of which is rapid extravasation in every 
direction, filling up the scrotum, spreading up over the pubes, and 
sometimes extending along the crest of the ilium as high as the 
false ribs. It is probably rare that this extensive secondary form 
of extravasation is not preceded by the circumscribed or primary 
form, hence the importance of the established rule of practice — to 
make a free opening into these hard swellings along the urethra as 
soon as their existence is ascertained. Another, and much more 
rare consequence of an opening of the urethra into the sheath, is 
the gradual formation of one or more fistulous tracks along the 
penis, terminating behind the corona glandis, and causing a good 
deal of thickening and induration of the tissues along their course." 1 

Voluntary Muscles. — It would be inconsistent with the limits of 
the present chapter to describe at length the various muscles which, 
correctly or incorrectly, have been supposed to act upon the urethra. 

1 Buck, op. cit., p. 370. 



236 STRICTURE OF THE URETHRA. 

Their anatomy is easily understood, and may be found in any ana- 
tomical text-book. Their physiological action is admirably de- 
scribed in Mr. Thompson's excellent monograph. The chief points 
of their relation to our present subject may be stated in a few 
words. 

The compressor urethrse — including under this name the transverse 
muscular layer described by Mr. Guthrie, the descending fibres of 
Mr. "Wilson, and the circular fibres of Muller — is a sphincter of the 
urethra surrounding the membranous region, and performing the 
same office for the bladder that the sphincter ani does for the rectum. 
Contraction of this muscle may contribute to the production of spas- 
modic stricture ; it often opposes the passage of an instrument, or 
renders its introduction painful, even when there is no obstruction 
in the canal ; it limits, to a great extent, the penetration of urethral 
injections from without, and prevents the exit of fluids injected by 
means of a catheter into the prostatic urethra. 1 

The anterior fibres of the levator ani, described by some authors 
as an independent muscle, under the name of "levator or com- 
pressor urethrae," encircle the prostate and neck of the bladder like 
a sling, and may assist in closing as well as elevating this portion 
of the urinary canal. 2 

The bulbo-cavernosus, by means of fibres which surround the 
corpus spongiosum and the corpora cavernosa, may exercise a 
similar office for the posterior portion of the spongy urethra. 

The muscles now mentioned are voluntary, and act under the 
direction of the will ; but the great abundance of organic muscular 
fibre, distributed around the urethra in situations already described, 
and the phenomena attendant upon the passage of urine and semen, 
leave no doubt that contraction of the urethra may take place as a 
purely reflex action. 

Dimensions, Mobility, and Direction of the Urethra. — Having con- 
sidered the separate portions of the urethra and the various tissues 
which surround it, we may now regard it as a unit; and more 
especially with reference to the size and form of instruments 
required in the treatment of stricture. 

The statements of authors relative to the length of the male 
urethra range from five and a half to twelve inches. This discrep- 
ancy may be accounted for by the different methods employed in 

1 See page 95. 2 Thompson, op. cit., p. 23. 



DIMENSIONS AND MOBILITY OF THE URETHRA. 237 

taking measurements ; whether upon the living or dead subject ; 
by the amount of traction exercised upon the parts ; and also ; to a 
certain extent, by an actual variation in different persons. The 
size of the penis appears to have no influence upon the length of 
the urethra ; the latter, as shown by Sappey's observations, 1 often 
being in an inverse ratio to the former. The greatest source of 
variation is found in the length of the anterior or ascending portion 
of the sub-pubic curvature. Without seeking for any absolute 
standard, it is desirable to obtain an average which may assist in 
determining the situation of strictures, and afford useful informa- 
tion in their treatment ; and after all that has been said by authors 
of the variable length of the urethra in different individuals, the 
results of measurements are found to be nearly identical, provided 
the method of making them be always the same. 

The length of the urethra may be estimated during life by means 
of a graduated catheter, the flow of urine indicating when the eye 
near its point has reached the vesical extremity of the canal, and 
care being taken that the penis is not stretched upon the instru- 
m«it. After death, the urethra and bladder may be removed 
from the body, slit open superiorly, gently extended upon some 
smooth surface, allowed to contract by their own elasticity, and 
then measured with a tape. Attempts have also been made to 
ascertain the length of the urethra by casts of the canal in fusible 
metal ; but the two methods just mentioned are far more reliable. 

According to the careful and minute observations of Mr. Thomp- 
son and Mr. Briggs, the results of measurements thus taken during 
life and after death are not identical ; by the former, the average 
length is found to be seven and one-half inches ; 2 by the latter, eight 
and one-half. This difference is constant, and may readily be 
accounted for by the different conditions under which the measure- 
ments are taken. It is worthy of remembrance, "since all accurate 
researches into the pathological anatomy of stricture are, of neces- 
sity, confined to an observation of the parts after death, while, in 
relation to treatment, the measurement during life is that which 
alone must be remembered." 3 

1 Recherches sur la Conformation Exterieure et la Structure de l'Uretre de 
l'Homme, Paris, 1854. 

2 Leroy d'Etiolles obtained an average of eight inches from one hundred mea- 
surements during life by means of a graduated gum-elastic sound. (Des RUrt- 
cissements de V Urelre, frc, Paris, 1845, p. 5.) 

3 Thompson, op. cit., p. 4. 



238 STRICTURE OF THE URETHRA. 

The urethra cannot be said to have any fixed and absolute 
diameter, since its walls admit of greater or less expansion accord- 
ing to the amount of force exerted upon them. A No. 12 catheter 
or sound of the ordinary scale rarely fails to pass with ease, if the 
parts be healthy ; and not unfrequently No.- 15 will pass without 
difficulty. 

It is more important to be familiar with the relative than with 
the actual diameters of the different portions of the canal. The 
external orifice or meatus is almost invariably the most contracted 
part; so that whatever instrument fairly enters the urethra will 
pass through it, if no obstruction exists. Another important infer- 
ence from this fact is, that to restore the original calibre by dilata- 
tion of one of the deeper portions of the urethra contracted by 
stricture, the meatus must be enlarged, which can generally be 
effected only by incision. The next narrowest point of the canal 
is at the junction of the bulbous and membranous regions ; while 
the middle of the prostatic portion, and the sinus of the bulb are 
the widest. 

The degree of mobility of different portions of the urethra* is 
chiefly influenced by the attachments of the neighboring fascise. 
The anterior part of the penis is free, and capable, in a flaccid con- 
dition, of assuming almost any position ; in its posterior third, how- 
ever, this organ is connected with the symphysis, by the suspensory 
ligament ; with the ischiatic and pubic rami, by the crura of the 
corpora cavernosa, and with the anterior layer of the deep perineal 
fascia, by means of the bulb ; the spongy urethra may, therefore, 
be said to be fixed in proportion as it approaches the membranous 
region. The membranous region is the least movable of all, owing 
to its firm connection with the pelvis by means of the two layers 
of deep perineal fascia. The prostatic urethra is susceptible of 
some slight change of position, dependent upon the action of the 
anterior fibres of the levator ani, and the amount of urine in the 
bladder. 

In a flaccid condition of the penis, the urethra has two curves ; 
the first confined to the anterior, the second to the deeper portion 
of the canal. The former is simply due to the dependent position 
of the anterior part of the organ, and is effaced in a state of erection 
or when the penis is elevated to an angle of about 60° with the body. 
The latter may be called the sub-pubic curve from its position 
beneath the symphysis. Unless some degree of force be used to 



DIMENSIONS AND MOBILITY OF THE UEETHEA. 239 

straighten the canal, this curve is permanent, and a knowledge of 
its direction is essential in determining the proper form of instru- 
ments and the manner of their introduction. 



Fig. 12. 




Sinm potularit 
or Utriculus 



Vertical section of bladder, penis, and urethra. (After Gray.) 

The sub-pubic curve commences an inch and a half anterior to 
the bulb, attains its lowest point, when the body is in the upright 
position, nearly opposite the anterior layer of the deep perineal 
fascia, and finally ascends through the membranous and prostatic 
regions. According to the observations of Mr. Thompson and Mr. 
Briggs, it "forms an arc of a circle, three inches and a quarter in 
diameter; the cord of the arc being two inches and three-quarters, 
or rather less than one-third of the circumference." Mr. Thompson 
states that he has often found it more acute in spare men ; and in 
the corpulent, more obtuse ; that traction of the abdominal muscles 
exercised through the suspensory ligament may also render it more 
abrupt, whence the advantage of raising the shoulders when per- 



240 STRICTUEE OF THE URETHRA. 

forming catheterization upon patients in the recumbent posture. 
The elevation of the bladder above the pubes in children, and the 
enlargement of the prostate so common in old men, also effect a 
change in the direction of the sub-pubic curve from its usual adult 
standard, and require therefore a corresponding variation in the 
form of instruments. Swellings and abscesses about the lower 
extremity of the rectum, large hemorrhoidal tumors, and various 
other circumstances may also operate in a greater or less degree to 
cause some change in the direction of this curve. 

STRICTURES. 

Strictures are most appropriately classified as Transitory, and 
Permanent. A transitory stricture signifies an abnormal contrac- 
tion of the urethra, capable of undergoing complete resolution 
through the action of natural forces. A permanent stricture is one 
dependent upon an organized, and consequently durable change in 
the tissues composing the urethral walls. 

Transitory Stricture. — The elements of a transitory stricture 
are muscular spasm, and congestion or inflammation. Either may 
exist alone; usually, both are combined. 

The observation of certain phenomena attendant upon strictures, 
and upon the introduction of instruments into the urethra, had, for 
many years, led surgeons to believe that spasmodic action was, 
in some instances, the sole cause of urethral contractions ; and that, 
in very many, it bore an important part in their production. At 
that time, however, the knowledge of muscular tissue surround- 
ing the urethra was chiefly confined to the compressor urethras ; 
consequently many authorities denied the influence of spasm, ex- 
cept perhaps in the membranous region, to which this muscle is 
limited. The subsequent discovery by Kolliker and Hancock of 
organic muscular fibres around the whole canal has shown the 
possibility, and, reasoning from analogy, the probability, that spas- 
modic contraction may take place in any part of the urethra; and 
repeated observation of facts of frequent occurrence leaves no 
farther doubt upon the subject. 

The phenomena of spasm are well known, and are the same in 
the urethra as in other parts of the body. Certain conditions of the 
general system predispose to it ; as, for instance, irritability of the 



TRANSITORY STRICTURE. 241 

nervous system, a gouty diathesis, congestion of the internal parts 
of the body from external influences ; as cold, moisture, etc. The 
exciting cause is generally some impression upon the sentient nerves, 
transmitted to a nervous centre, and returned through motor fibres, 
terminating in either voluntary or involuntary muscles. In the 
urethra, spasmodic action, sufficient to produce stricture, may take 
place in the sub-mucous layer of organic fibres common to the 
whole canal ; or, in the membranous region, in the striped fibres of 
the compressor urethras ; and, perhaps, to a less extent, in those of 
the acceleratores in the spongy region. 

While performing catheterization upon irritable subjects, it has 
occasionally been observed by nearly every surgeon, that the instru- 
ment is grasped and temporarily held by the urethral walls, even 
when the canal is free from permanent obstruction. In this case, 
the sound, or catheter, acts as a foreign body, and the irritation 
which it produces is followed by contraction in accordance with 
the familiar laws of reflex action. 

In other cases, the eccentric irritation is caused by laceration, 
abrasion, or a wound of the lining membrane, such as may ensue 
from the rough use of a catheter, or other surgical instrument. 
This, of itself, may excite spasm ; or the same may be induced by 
contact of urine with the raw surface. The presence of some degree 
of congestion or inflammation, provided it be not sufficient to ob- 
struct the canal, does not render the term "spasmodic stricture" 
inappropriate. 

Striking examples of spasmodic stricture are also met with as 
the result of irritation about the rectum, excited by the presence 
of a tapeworm, ascarides, haemorrhoids, fissure of the anus, fecal 
accumulation ; or by operations upon this part, especially the liga- 
ture of piles. Sir Benjamin Brodie 1 met with a case of spas- 
modic stricture, in which the spasm was intermittent, recurring 
every twenty-four or forty-eight hours, and which was finally cured 
by quinine after the failure of other means. 

Among other causes of spasm, are the presence of a stone in the 
bladder, or urethra ; immoderate sexual intercourse ; the free use 
of alcoholic stimulants ; long retention of the urine ; horseback 
exercise ; digestive derangements ; exposure to sudden changes of 
temperature, and mental emotion. 

' London Medical Gazette, vol. i. p. 507. 

16 



242 STRICTURE OF THE URETHRA. 

A spasmodic stricture is characterized by its snort duration, and 
the absence of severe pain in the urethra. It appears suddenly 
in persons of delicate habit, especially in those who have commit- 
ted some imprudence in diet, and as suddenly disappears. Explo- 
ration of the canal by means of a sound after the spasm has passed, 
and frequently during its continuance, shows that there is no organic 
obstruction. Mr. Smith 1 details a case in which a patient, who had 
suffered from a violent attack of retention a short time before, sud- 
denly died ; and, at the post-mortem examination, not the slightest 
contraction was found. 

Swelling is so constant an effect of inflammation as to be reck- 
oned among its characteristic symptoms. In every acute attack of 
urethritis, the calibre of the urethra must be more or less dimin- 
ished ; and that this is a fact, is evidenced by the diminution of 
volume in the stream of urine. The swelling of the mucous mem- 
brane is due in part to distension of its capillaries, and in part to 
infiltration of serum, or, sometimes, of more plastic material. In- 
flammatory products may become organized, and thus lay the foun- 
dation of permanent stricture ; though, in most cases of acute 
gonorrhoea, they are soon absorbed, and the calibre of the urethra 
restored. Inflammatory or congestive stricture usually occurs in 
persons of a robust habit, in whom urethritis is decidedly acute, 
and is attended by very severe pain in the perineum and course of 
the urethra, and scalding in passing water ; the penis is more or less 
turgescent, the lips of the meatus decidedly vascular, and the pa- 
tient feverish. 

In the great majority of cases, however, which come under the 
observation of the surgeon, inflammation and spasm are combined ; 
or to these is added some degree of permanent contraction. A 
patient has an organic stricture, which has given him but little 
annoyance, and offered no serious obstacle to the complete evacua- 
tion of the bladder ; suddenly, after freely indulging in spirits, or 
coitus, and retaining his urine for several hours, he finds himself 
utterly unable to pass water. The urethra, partially contracted by 
organized deposit in and around its walls, is entirely closed by the 
supervention of congestion and spasm, and complete retention is 
the result. Under appropriate treatment, the congestion and spasm 
may be subdued, though the organic stricture remains after their 
disappearance. 

1 Henry Smith, Stricture of the Urethra, London, 1857, p. 23. 



PERMANENT OR ORGANIC STRICTURE. 243 

The treatment of spasm and inflammation will be considered in 
the following pages, especially in connection with retention of urine, 
in the causation of which they constitute such important elements. 

Permanent or Organic Stricture. — The albuminous fluid 
which infiltrates the tissues in acute urethritis, and which may con- 
tribute to the formation of congestive stricture, is, in most cases, 
eventually absorbed, and the canal recovers its normal calibre. 
But under other circumstances, and especially as a consequence of 
chronic inflammation, products of a more plastic nature are thrown 
out, which become organized, exhibit the same tendency to contract 
as adventitious deposit in other parts of the body, and give rise to 
permanent contractions of the canal. 

The seat of, this fibro-plastic deposit is commonly in the sub- 
stance of the lining membrane, in the cellular tissue beneath it, and, 
in severe cases, in the more external tissues. Mr. Thompson's 1 
observations show that, in its incipiency, an organic stricture may 
consist of a mere thickening of the mucous membrane, hardly dis- 
cernible when the urethra is laid open, and only evident on close 
inspection of a longitudinal SQction ; at a stage slightly more ad- 
vanced, the lining membrane loses its transparency, becomes puck- 
ered, is firmly adherent to the deeper tissues, and transverse fibres 
are found beneath, which encircle the canal like a purse-string ; 
finally, in the most severe form, the meshes of the submucous tis- 
sue are filled with organized lymph, the fibres of organic muscle 
can no longer be detected, and the adventitious deposit may involve 
the substance of the corpus spongiosum, or even extend to the 
corpora cavernosa ; giving to the penis a hard, nodulated feel, evi- 
dent during life on external examination. 

This organized material is found under the microscope to be 
identical with inflammatory products effused in other parts of the 
body, the tendency of which to contract and harden is well known. 
Mr. Thompson compares it to the interstitial deposit in the liver 
producing cirrhosis, to the lymph poured out in pleurisy, and to 
the substance of cicatrices following burns. The nature of this 
tissue fully explains the admitted necessity of long-continued dila- 
tation to restore the original calibre of the contracted part, and the 
constant tendency which strictures exhibit to return, when once 
apparently cured, a tendency which is so universal, that Cruveilhier 2 

1 Op. cit., p. 55. 2 Anatomie Pathologique du Corps Humain. 



244 STRICTURE OF THE URETHRA. 

has pronounced stricture of the urethra absolutely incurable. It is 
evident, moreover, that the diminution in the calibre of the urethra 
is but one of the bad effects of stricture ; the normal elasticity of 
the canal is lost, and the exercise of its function seriously inter- 
fered with. 

In exceptional cases the urethra is obstructed by the deposition 
of a false membrane within its walls without any external constric- 
tion, in a manner analogous to the effusion upon the trachea and 
bronchi in croup. Mr. Hancock 1 describes the appearance pre- 
sented at several post-mortem examinations which he had the op- 
portunity of making, as follows : " The membrane was straw-colored, 
and for the most part adhered so firmly to the mucous membrane, 
that it was only by careful dissection we could separate the one 
from the other ; indeed, so identified were the two, that had we 
remained content with a mere cursory or superficial examination, 
we might have imagined the morbid appearances to have depended 
upon thickening and puckering of the mucous membrane itself, 
rather than upon what actually obtained. It was only by the mi- 
croscope that we could determine what was really the condition of 
the parts. The existence of this fajse membrane was proved by 
some points of great interest; among others, that although this 
newly-deposited structure appeared to be invested by mucous mem- 
brane when examined by the naked eye, the investment, though 
smooth and shining, did not possess the actual organization of mu- 
cous membrane, but, when viewed through the microscope, presented 
more the character of condensed cellular tissue. It did not possess 
either villi or papillae upon its free surface ; it was not invested by 
epithelial scales ; and, what was extremely interesting, as incontro- 
vertibly proving the non-identity of this membrane with the proper 
mucous canal, we found that by carefully dissecting it away, we 
came down upon the layer of epithelial scales separating it, as it 
were, from the proper mucous membrane of the urethra." Occa- 
sionally, according to Mr. Hancock, the posterior portion of the 
membrane is detached, and may constitute a valve ; which, while 
offering little if any obstruction to a sound, may completely cut 
off the passage of the urine. "Primary croup" of the urethral 
mucous membrane is admitted by Rokitansky, 2 who states that it 
chiefly occurs in children. Mr. Thompson, in his examination of 

1 Strictures of the Urethra, etc., London, 1852, p. 76. 

2 Syd. Soc. ed., vol. ii. p. 235. 



PERMANENT OR ORGANIC STRICTURE. 245 

pathological collections in various museums, has found but three 
specimens of stricture which could be attributed to false mem- 
branes, and in two of these he is of the opinion that the appear- 
ances were due to dilated lacuna? ; it is probable, therefore, that the 
cases described by Mr. Hancock are extremely rare. 

A deposition of an entirely different character from that just 
described — with which, however, it may be confounded — is not 
unfrequently met with covering the urethral walls at the site of a 
stricture. It consists of a copious secretion of pasty mucus, " which 
may or may not be attended with an exuberant formation of epi- 
thelium, and in which, accordingly, the epithelium is either rapidly 
thrown off from an almost bare and, as it seems, excoriated mucous 
membrane, or accumulates over the whole or over parts of the 
surface, and thus forms a complete laminated covering for it, or 
patches of various thickness here and there upon it." 1 This pasty 
exudation is always the result of chronic inflammation, while the 
croupy deposit before described is due to that of an acute form. 

In former times, when pathological anatomy was rarely studied 
minutely upon the dead body, all strictures were supposed to be 
due to fungous growths within the canal, which encroached upon 
its diameter and presented an obstacle to the passage of urine and 
the introduction of instruments. Subsequent observation has shown 
that such excrescences are very rarely the cause of obstruction, 
although they are sometimes met with. They have been observed 
and described by Soemmering, Laennec, Charles Bell, Leroy 
d*Etiolles, Amussat, Eicord, Mercier, Mr. Henry Thompson, and 
others. Dr. Gross 2 says that he has "several times seen fleshy 
growths in the urethra ;" and, from my own experience, I can testify 
to the not unfrequent occurrence of vegetations in the fossa navicu- 
laris in persons bearing similar growths upon the preputial mucous 
membrane. In this situation, however, I have rarely found them 
to seriously affect the exercise of the urethral function. 

These "fungi, carnosities, caruncles, or excrescences," as they have 
been variously termed, may consist of a development of the mucous 
papillae, like external warts upon the prepuce ; of ordinary granu- 
lations springing from an ulcerated surface ; of true polypi ; and, 
rarely, of tubercular or cancerous growths. Mr. Thompson states 

1 Rokitansky, op . cit., vol. iii - p. 51. 

2 Practical Treatise on the Diseases, etc., of the Bladder, Prostate Gland, and 
Urethra, 2d ed., p. 759. 



246 STRICTURE OF THE URETHRA. 

that the first variety mentioned is most frequent in the spongy 
region ; that polypoid growths are confined to the prostatic urethra ; 
and that tubercle and cancer are never primary formations, but 
always consecutive to their development in other portions of the 
urinary organs. 

Strictures dependent upon varicose enlargements were at one 
time admitted, but their existence is not borne out by post-mortem 
examinations. The hemorrhage which sometimes attends the 
introduction of instruments, and is occasionally excessive, generally 
proceeds from vascular granulations, an abraded surface, or a 
wound of the spongy tissue which surrounds a large portion of 
the urethra. It is probable that, in most cases, there is increased 
fulness of the vessels in the neighborhood of a stricture during 
life, although it is not always apparent after death. 

Dr. Jameson relates the case of an aged seamen who had long 
labored under severe stricture and habitual retention, and at whose 
post-mortem, the "whole of the membranous portion of the urethra 
was found ossified, and reduced to the size of a crowquill." 1 Not- 
withstanding the high authority on which this statement is made, 
it appears to me probable that the appearances observed were due 
to the deposition of calculous matter imbedded in the urethral 
walls, and not to true ossification. 

Finally, stricture may depend upon specific induration surround- 
ing an infecting chancre, concealed within the urethra ; of which 
Eicord states that he has met with many examples. 

• 

Seat. — There are several sources of error which should be avoided 
in attempts to determine the anatomical seat of strictures during 
life. These are the difference in the estimated length of the nor- 
mal urethra, as given by different authors; the mobility of the 
stricture itself, which may often be thrust back to a considerable 
distance on the point of an instrument ; the liability of the penis to 
be elongated by traction at the time of taking the measurement ; 
and the actual elongation which often ensues as a consequence of 
the frequent handling which this organ receives from persons 
suffering under stricture. The great discrepancy in the statements 
of authors as to the most frequent seat of this complaint shows 
that these, and perhaps other sources of error have not been suffi- 

1 An Essay on Strictures of the Urethra, by H. G. Jameson, M. D., Surgeon to 
the Baltimore Hosp., Am. Med. Recorder, 1824, vol. vii. p. 251. 



SEAT— EXTERNAL ORIFICE. 247 

ciently guarded against ; and the tendency has almost invariably 
been, as shown by recent investigations, to assign to stricture a 
seat posterior to its true situation. 

I shall not waste time in quoting the different opinions which 
have been expressed upon this disputed point, but refer at once to 
the results obtained by Mr. Thompson from a careful and laborious 
examination of over three hundred preparations of stricture con- 
tained in the chief museums of Paris, London, and Edinburgh. 
It is only in this manner, by post-mortem inspection, that the 
locality of stricture can be ascertained with certainty and accuracy ; 
and Mr. Thompson's conclusions will doubtless be regarded as 
decisive, until controverted by an examination of a still larger 
number of specimens, conducted with equal care and fidelity — an 
event not likely soon to happen. 

In relation to the locality of stricture, Mr. Thompson divides 
the urethra into the three following regions : — • 

I. The Sub-pubic Curvature ; which comprises an inch of the 
canal before, and three-quarters of an inch behind, the junction 
between the spongy and membranous regions, thus including the 
whole of the membranous portion. 

II. The Centre of the Spongy Portion, a region extending 
from the anterior limit of the preceding, to within two inches and 
a half of the external meatus, and measuring therefore about two 
and a half to three inches in length. 

III. The External Orifice, including a distance of two 

INCHES AND A HALF BEHIND IT. 

Of 270 preparations, embracing 320 distinct strictures, Mr. Thomp- 
son found 

In region I . . . 215 or 67 per cent. 
" " II . . . 51 " 16 " " 

" " III .. . . 54 " 17 " " 



320 
It is thus seen that by far the largest number of strictures are 
situated at the sub-pubic curvature ; and the most frequent locality 
may be still further limited to the anterior portion of this region, 
as appears from the following statement by Mr. Thompson : 
"That part of the urethra which is most frequently affected with 
stricture is the portion comprised in the inch anterior to the junc- 
tion, that is, the posterior or bulbous part of the spongy portion. 



248 



STRICTURE OF THE URETHRA. 



The liability of this part to stricture appears to diminish as it ap- 
proaches the junction, where it is less common ; while behind, it is 
very rare. Most rarely is a stricture found so far back as the pos- 

Fig. 13. 



Region No. III. 



The spongy portion 



The membranous 
portion. 



The prostatic 
portion. 




Region No. II. 



Region No. I. 



/'j 



"A healthy urethra, eight inches and a half in length, slit up from the upper part, accurately 
reduced on scale from a drawing made from the original while fresh, to half the natural size. On 
the left-hand side are indicated the anatomical divisions of the urethra, and on the right the 
boundaries of the regions referred to in relation to the locality of stricture." (Thompson.) 

terior part of the membranous portion." 1 The next most frequent 
situation of stricture is the external two and a half inches, and the 
least frequent the middle portion of the spongy region, although 
the difference between the two is not very great ; while both are 



1 Op. cit., p. 83. 



NUMBER. 249 

of but small importance compared with the anterior portion of the 
bulb. 

Mr. Walsh 1 has arrived at results identical with those of Mr. 
Thompson, from an examination of the preparations in the Eoyal 
College of Surgeons of Dublin ; and in reviewing the observations 
of other surgeons, it is found, as a general rule, that, whenever their 
statements have been based upon post-mortem investigation, they 
do not differ materially from those here given. 

M. Mercier, 2 who has probably paid more attention to the anatomy 
and pathology of the genito-urinary organs than any other French 
surgeon, states that strictures are almost exclusively limited to the 
spongy portion of the urethra, and are most frequent at the bulb. 
He believes that it is quite exceptional to meet with them as far 
back as the membranous portion. 

It will be observed that no mention has been made of the pros- 
tatic portion of the urethra; a region which Sir Astley Cooper 
asserted was even second in the relative frequency of stricture. 
There can be no doubt that hypertrophy of the prostate was formerly 
mistaken, in many instances, for organic contraction of the canal ; 
and recent observations show, that stricture of the prostatic urethra 
is so extremely rare that doubts of its existence are not unrea- 
sonable. Mr. Thompson states unhesitatingly that there is not 
a single case to be found in any of the public museums of London, 
Edinburgh, or Paris. Mr. "Walsh describes a preparation in the 
Museum of the Eoyal College of Surgeons in Dublin, in which a 
stricture commences in the posterior part of the membranous, and 
extends into the prostatic portion, causing a well-marked contrac- 
tion. Mr. Crosse described and figured a case of prostatic stric- 
ture ; Leroy D'Etiolles 3 and Eicord 4 say they have met with them ; 
and Civiale 5 speaks of one. 

In conclusion, it may be stated that modern investigation would 
appear to show that strictures are found only in those portions of 
the urethra which are surrounded by erectile tissue ; and are most 
frequent where the latter is most abundant ; hence, their most com- 
mon seat is in the bulb, next in the remainder of the spongy por- 

• Dublin Medieal Press, Jan. 23, 1856, p. 51. 

2 Recherches sur le Traitement des Maladies des Voies Urinaires, 1856, p. 376. 
Also Bulletin de la Societe Anatomique de Paris, 1858, p. 441. 

3 Des Retrecissernents de l'Uretre, Paris, 1845, p. 83. 

4 Notes to Hunter on Venereal, 2d ed., Phil., 1859, p. 168. 

5 Maladies des Organes Genito-urinaires, 2d ed., Paris, 1850, vol. i. p. 158. 



250 STRICTUKE OF THE UEETHRA. 

tion, and finally in the membranous region, which is also invested 
with a thin layer of vascular tissue. In harmony with this law, 
the thickest portion of a stricture* surrounding the bulbous urethra 
is below the canal, corresponding to the greater thickness of the 
erectile tissue in this direction. 

Number. — In most cases there is only one stricture in the same 
subject. Of 267 preparations examined by Mr. Thompson, the 
stricture was single in 226. Occasionally there are several distinct 
contractions. Hunter 1 met with six ; Colot with eight ; and Ducamp 
with five ; but Boyer never found more than three, and Mr. Thomp- 
son 2 never more than " three, or at the most, four." Civiale 3 says 
that when there are several, one of them is almost always situated 
in the sub-pubic curve, and the others between it and the meatus. 
It is to be understood in these remarks, that distinct strictures are 
alone referred to. The urethra is sometimes contracted for a con- 
siderable distance, several points of which are more constricted 
than others ; but these are not to be regarded as separate strictures. 
Lengthy strictures are more frequently found in the spongy region 
than in the sub-pubic curve ; and instances are recorded in which 
they have extended from the meatus nearly to the bulb. 

Form. — The form of stricture necessarily varies with the amount 
and situation of the fibrinous deposit which produces it. This may 
consist of a few fibres, which encircle the whole or a part of the 
urethral circumference, like a thread, or may form a band, varying 
in extent and thickness. In the former case, the stricture, composed 
of a fold of mucous membrane inclosing the constricting fibres, has 
the appearance of a membranous diaphragm, which may embrace 
the whole or a part of the canal — in the one case like a narrow ring, 
and in the other like a crescent ; it sometimes runs obliquely, in- 
stead of directly across the urethra ; occasionally it is pierced by 
one or more holes. This is the " linear stricture" of Mr. Thompson 
and others ; the " bridle stricture" of Charles Bell ; and the " val- 
vular stricture" of French writers. A rare variety of this form of 
stricture is a small narrow band stretched from side to side, or cross- 
ing the canal diagonally, and dividing the urethra into two portions. 
Mr. Thompson speaks of a preparation in the Museum of St. Bar- 
tholomew's Hospital, in which there are ten or eleven of these free 
bands, which this author is inclined to ascribe to short false pas- 

1 Ricord and Hunter, op. cit., p. 168. 2 Op. cit., p. 54. 3 Op. oit., vol. i. p. 157. 



DEGREE OF CONTRACTION. 



251 



sages. These bridles are sometimes of considerable size, as in an- 
other preparation of the same museum, in which the urethra is con- 
tracted throughout its whole length, and a rough, fibrous band, an 
inch in length, and attached only by its extremities, extends from 
the verumontanum forwards, to the membranous part of the urethra. 
Where the fibrinous deposit is more extensive, the stricture 
covers a larger portion of the urethral walls. In some instances, it 
is abrupt on either side, like the last mentioned form, but wider ; as 
if a whip-cord were tied externally to the mucous membrane ; this 
is called an " annular stricture." If the induration be more diffused 
around its base, a section of the canal will resemble an hour-glass, 
and the contraction receives the name of " indurated annular stric- 
ture." Mr. Thompson states that thickening of the tissues is gener- 
ally greater on the lower than on the upper surface. Again, stric- 
ture may involve the canal to the extent of half an inch or several 
inches ; when the passage is often more or less deviated from its 
normal direction, and the stricture is said to be " irregular or tor- 
tuous." It is chiefly in these cases that the induration is so exces- 



Fig. 14. 



Fig. 15. 





Fig. 14. Annular stricture. 

Fig. 15. Irregular, or tortuous stricture. Posterior to the stricture in each figure, are seen 
pouches of the mucous membrane, formed by dilatation of the lacunae and ducts, and capable of 
entangling the point of an instrument. (After Thompson.) 

sive as to implicate the whole thickness of the corpus spongiosum, 
or even a portion of the corpora cavernosa, and form hardened 
masses which are readily perceived by the finger during life. 



252 STRICTURE OF THE URETHRA. 

Degree of Contraction. — The plastic material of stricture exhibits 
a constant tendency to contract, and become harder and firmer with 
time ; it is consequently true, as a general rule ; that the longer a 
stricture has existed, the more callous it is, and the less susceptible 
of dilatation. Exceptions to this law, however, sometimes exist ; 
and strictures of long duration are met with which yield readily, 
while others, recent in their origin, prove very obstinate. Again, 
there is a class of strictures which are amenable to the process of 
dilatation, but which rapidly contract again, and in a very short 
time after the cessation of treatment, are as narrow as ever. They 
are most frequently found in the bulbous and spongy portions of 
the urethra, where the character of the surrounding tissues admits 
of a more extensive effusion of plastic material than in the deeper 
parts of the canal. They constitute the " resilient stricture" of Mr. 
Syme. When two strictures are present — one in the anterior, and 
the other in the posterior portion of the urethra — the latter will 
generally be found to dilate much more rapidly than' the former. 

Complete obliteration of the urethra may take place as a conse- 
quence of a wound of the canal, sometimes from within, but more 
frequently from without. In stricture, other than those of traumatic 
origin, the urethral walls are probably never completely fused 
together; although cases are reported in which fistulous passages 
had for a long time turned the urine from its normal channel, and 
in which, on post-mortem examination, it was impossible to intro- 
duce the finest probe through the contraction, even after the ex- 
ternal portion of the penis had been slit up. 1 Instances of this 
kind, however, are rare; in most cases, however great the narrow- 
ing, urine will still find its way out, though it may be only by a 
few drops at a time. 

There has been no little discussion of the question, whether the 
urethra, when permeable to urine, is always permeable to instru- 
ments, a question of importance in its bearing upon perineal section 
as advocated by Mr. Syme, Professor of Clinical Surgery in the 
University of Edinburgh. Some misconception of Mr. Syme's 
views has at times been entertained, and it has been supposed that 
he asserted the immediate permeability of strictures under all cir- 
cumstances. The true opinion of this surgeon will be best given 
in his own words. He says : " As to the question of ' impermeability,' 
I simply maintain, that if the urine passes out, instruments may 

1 Thompson, op. cit., p. 60-1. 



DEGREE OF CONTRACTION. 253 

always, through care and perseverance, be got in beyond the con- 
traction. It should be observed that the case here is quite different 
from that of a distended bladder requiring immediate relief. I have 
never maintained that in such circumstances the introduction of a 
catheter was always practicable." l 

Mr. Liston previously took similar ground, and asserted that he 
had never seen impassable stricture; "for, when any water comes 
away, you can, by patience and perseverance, get a catheter through, 
sooner or later." 

Dr. Phillips holds the same views as Mr. Syme. In his Traite 
des Voies Urinaires, 2 he says: "Mr. Syme asserts that no stricture 
is impassable; whenever the urine can find exit, even in a few 
drops only, a fine bougie can be introduced. I am entirely of this 
opinion, however absolute it may appear." Dr. Phillips has ac- 
quired considerable reputation in Paris by performing catheterism 
in cases where Nelaton and other surgeons had failed; but this 
success has been attained in some instances only after attempts re- 
peated and prolonged to a greater extent than is usually considered 
justifiable. In one case six sessions of three hours each were re- 
quired, and when the reader is informed that Dr. Phillips always 
places the patient during catheterization in the standing posture, it 
will be seen that no small amount of endurance is required. 

Mr. Syme's views have not been generally adopted by the pro- 
fession at large. They have excited much opposition abroad ; and, 
in this country, I think I can safely say that no surgeon of any 
considerable experience will maintain that he has never seen an 
"impassable stricture;" yet the records of surgery will show that 
the surgeons of America are not behind those of other countries in 
skill and manual dexterity. In the latter years of his life, Mr. 
Liston was repeatedly foiled in attempts to introduce a catheter, 
and Mr. Cadge, who assisted this surgeon in his operations for 
some time before his death, says: "I have notes of four cases in 
which, after repeated unsuccessful attempts to introduce an instru- 
ment, Mr. Liston secured the patients as for lithotomy, and opened 
the urethra by an incision in the perineum." The great advocate 
of permeability, Mr. Syme himself, has also been foiled, as will ap- 
pear from the following confession in the second edition of his 
work: 3 "In many cases, I have had to wait days, or even weeks, 

1 Edinburgh Monthly Journal, June. 1851. 

2 Page 194. 3 Pp . 33 _ 36# 



254 STRICTURE OF THE URETHRA. 

before the passage could be bit. Indeed, on three occasions — one 
in private and two in public — I found it necessary to open tbe 
urethra anteriorly to tbe stricture, so as to obtain tbe assistance of 
a finger placed in tbe canal, to guide tbe point of tbe instrument." 
As intimated by one of bis reviewers, "this is most suspiciously 
like a 'buttonhole' contrivance, and unavoidably suggests tbe idea 
of a back door in tbe operator's argument." 

It is not intended by these remarks to disparage the skill, gentle- 
ness, and perseverance which will often triumph over an obstinate 
stricture, when less able hands have failed. It is to be recollected, 
too, that the greater the surgeon's confidence in his instrument, the 
more likely he will be to succeed. It may be admitted, also, that 
where tbe necessary qualifications are present, instances of failure 
are rare ; but to claim that such never occur, exceeds the bounds 
of truth, and is calculated to discourage the student in the use of 
the catheter. In the words of one of our most eminent surgeons, 
"I assert, upon the testimony of personal experience, the best test 
of all, that there is a class of strictures, the result of ordinary causes, 
which, while they admit of the passage of urine, slowly and imper- 
fectly it may be, do not permit tbe introduction of any instrument, 
however small, into the bladder." 1 

After all, may it not be said with truth, that the difference of 
opinion upon this question is rather one of words than of facts ? 

Dr. Phillips and Dr. meet with a case of stricture, in which 

they both fail to introduce an instrument on the first or second 
trial. Tbe latter surgeon calls it "impassable," while the former 
repeats his attempts indefinitely until success is attained, and calls 
it "passable." Dr. Syme finds an obstruction which he can only 
pass after making an incision in the perineum and obtaining tbe 
assistance of a finger introduced through the wound, and calls it 
"permeable." Dr. does the same thing, and calls it "imper- 
meable." 

PATHOLOGY OF STRICTURE. 

In mild cases of stricture, tbe canal in front of the contraction 
preserves its normal dimensions and character; but in severe and 
chronic cases, when tbe flow of urine has been much obstructed, 

1 Gross, Diseases of the Urinary Bladder, etc., 2d edition. Philadelphia, 1855, 
p. 763. 



PATHOLOGY OF STRICTURE. 255 

and the anterior portion of the urethra, either through sympathy 
or continuity of tissue, has participated in the inflammation which 
chiefly affects the part behind the stricture, it is contracted ; another 
condition, difficult of explanation, is one of dilatation, which, in a 
case described and figured by Charles Bell, was very considerable. 
Instances in which the urethra was ulcerated in front of the stric- 
ture, are also given by the same author. 

Posterior to the stricture, the urethra is generally enlarged, as a 
natural consequence of the impediment to the free evacuation of 
the bladder. The canal ultimately loses its elasticity and becomes 
dilated so as readily to admit the finger, or even form a pouch 
which may appear as a fluctuating tumor in the perineum. Sir 
Benjamin Broclie relates the case of a patient who had a stricture 
at the distance of three inches behind the external meatus; whenever 
he made water, a tumor presented itself in the perineum, as large 
as a small orange, which was punctured with a lancet, and gave exit 
to a full stream of urine, which was allowed to flow through the 
artificial opening until the stricture had been effectually treated by 
dilatation. 1 The lacunae of the mucous membrane and the orifices 
of the prostatic and ejaculatory ducts frequently participate in this 
enlargement ; and the septa between the pouches thus formed con- 
stitute a network, chiefly confined to the floor and sides of the 
canal, which is well adapted to obstruct the passage of an instru- 
ment unless the point be well elevated towards the pubis. This 
condition is represented in Figs. 14 and 15, taken from Mr. Thomp- 
son's work. In consequence of continued pressure, the prominence 
of the verumontanum may also be entirely effaced. The prostatic 
portion of the urethra is particularly susceptible of the dilation now 
described, while the membranous is less so; indeed, when the stric- 
ture is situated in front of the triangular ligament, the latter portion 
may retain its normal calibre — a fact to be remembered in relation 
to perineal section, otherwise in performing this operation in cases 
of impassable contractions, dilatation of the urethra may be sought 
for as a guide to the incisions, when it does not exist. 2 When there 
are several strictures, the urethra is commonly somewhat dilated 
between 'them. 

The mucous membrane, especially behind the stricture, is the seat 
of chronic inflammation ; it is sometimes contracted and puckered ; 

1 Lectures on the Diseases of the Urinary Organs. Philadelphia, 1847, p. 12. 

2 Guthrie, London Lancet, Am. ed., Sept. 1851, p. 173. 



256 STRICTUEE OF THE URETHRA. 

and sometimes thin, and minntely injected with bloodvessels; 
the surface is generally covered with a layer of pasty exudation, 
and it is from this source and from the bladder that the gleety dis- 
charge, which is so constant an attendant upon stricture, is derived. 
Ulceration frequently takes place, which may be superficial, or 
which may extend to the deeper tissues, producing large and ragged 
excavations of the urethral walls, or, in rare instances, it may even 
occasion destruction of the contracted portion of the canal. A 
patient, under the care of Sir Benjamin Brodie, 1 suffered from very 
severe pain at the site of his stricture for several days, after which 
his condition was much improved and he passed water better than 
he had done for years ; the whole train of circumstances indicating 
that the stricture had been destroyed by ulceration. 

Abscess and Fistula. — A still more serious consequence of stricture 
is the development of abscess and fistula in the neighborhood of 
the urethra. In most cases their mode of origin resembles the for- 
mation of abscess and fistula around the rectum; the urethral 
mucous membrane is impaired or destroyed at one or more points 
by ulceration ; during the straining of micturition, urine, perhaps in 
a very minute quantity, escapes into the cellular tissue ; an abscess 
is formed which burrows in various directions, or which opens and 
establishes a fistulous communication between the external sur- 
face and the urethra. In other cases, abscesses are developed 
without rupture of the urethral walls or infiltration of urine ; and 
they may even occur, when the obstruction to the evacuation of 
the bladder is far from complete. They can only be ascribed to 
the irritation produced in the surrounding parts by the presence of 
the stricture, especially if this be heightened by a careless use of 
instruments. Numerous post-mortem examinations have shown that 
there may be no connection between an abscess dependent upon 
stricture and the urethral canal ; in many cases, however, a com- 
munication is subsequently established by the ulcerative process. 
When a urethral opening exists, it is generally behind the con- 
tracted part, but sometimes in front of it. Instances of urinary 
abscesses anterior to strictures have been recorded by Civiale, 2 
Caudmont, 3 and others, and occasional specimens are found in va- 
rious public museums. The course taken by urinary fistulse is 

■ Op. cit., p. 16. ? Op. cit., p. 505. 

3 Bulletin de la Soc. Anatornique de Paris, 2e serie, t. iv. p. 109. 



ABSCESS AND FISTULA. 257 

often very erratic ; they may open into the rectum, upon the 
perineum, upon the surface of the scrotum, the lower part of 
the abdomen, or upon the thighs or nates. Thompson 1 refers to 
two specimens, in one of which the fistula traversed the thyroid 
foramen, and in the other terminated at the umbilicus ; and a 
preparation was presented at the Societe de Chirurgie, of Paris 
(Sept. 21, 1859), in which a fistula, originating in the bladder, 
passed through the horizontal ramus of the pubis, and terminated 
by several openings in the thigh ; it is probable, however, that the 
patient, in addition to his stricture, had disease of the pubic bone, 
to which the bladder had become adherent. 

These abnormal passages rarely have more than one opening into 
the urethra, but very frequently a number upon the external 
surface ; in one case, seen by Civiale, the latter amounted to no less 
than fifty-two. 2 Their internal surface becomes lined with adventi- 
tious tissue, which bears a very close resemblance to mucous mem- 
brane, but is destitute of glands and follicles; it is organized, 
well supplied with nerves, bloodvessels, and absorbents, and con- 
stantly secretes a muco-purulent fluid. Their walls are so firm, 
that the passage can often be traced like a cord underlying the 
skin. When numerous, the cellular tissue between and around 
them may become condensed through chronic inflammation into 
a hard, brawny mass, and the natural suppleness, if not the shape 
of the part, be lost. If the urethra be impermeable, the urine flows 
entirely through these abnormal channels : if pervious, more or 
less may still trickle away with each evacuation of the bladder. 
Calculous matter is deposited in fine particles or in larger masses, 
resembling mortar, upon the walls, and more particularly near the 
orifices or in some blind pouch opening into the passage. 

Deposition of similar matter often takes place in the dilated 
sinuses of the prostate already described. This gland, moreover, 
may become inflamed and abscesses form in its substance, which 
may remain for a long time circumscribed, open into the urethra, 
or effect a communication with the rectum or cellular tissue of the 
pelvis ; or the prostate may be reduced to a pultaceous mass sur- 
rounded apparently by a membranous pouch, in which its normal 
structure can no longer be distinguished. ' Stricture of the urethra 
was formerly considered a frequent cause of senile enlargement of 

1 Op. cit.. p. 68. 2 p. cit., voL i. p. 539. 

17 



258 STRICTURE OF THE URETHRA. 

the prostate, but numerous examinations of the dead and living 
subject have shown that the two rarely coexist, and that there is 
probably no connection between them. 1 

Bladder. — That increased action shall be followed by increased 
development is a general law of the animal economy. For the 
same reason that the blacksmith's arm grows large and powerful, 
the vesical walls become hypertrophied, as a consequence of the 
obstruction to the flow of urine and the additional force requisite 
for its expulsion induced by stricture. This hypertrophy chiefly 
affects the muscular layer, but does not wholly spare the areolar 
tissue, which is somewhat thickened and increased in density. 
The walls of the bladder may attain five or six times their normal 
thickness, and measure from half an inch to an inch in thickness. 
The developed fasciculi of muscular fibres form prominent ridges 
upon the mucous surface, and have been aptly compared to the 
columnas carnese of the heart's cavities. Frequent and violent 
expulsory efforts cause protrusion of the mucous membrane be- 
tween these columns, and pouches are formed, which, small at first, 
may gradually increase in size until they equal or excel the di- 
mensions of the bladder itself. Their development is favored by 
the fact that they are chiefly composed of mucous membrane with 
an imperfect layer of muscular fibres, a little areolar tissue and 
the peritoneum externally, and are therefore thinner, weaker, 
and less resistant than the proper vesical coats. There are fre- 
quently from three to six of these pouches, and sometimes many 
more; their communication with the bladder is often through a 
very small opening, which, in a preparation in the London Hospital 
Museum, does not exceed an ordinary goose-quill; in many in- 
stances they contain sandy particles, or fully formed calculi, which 
may have found entrance from the bladder, or, more frequently, 
are developed in the cavity. Eupture of their walls, escape of 
urine into the abdominal cavity, and consequent death, have been 
known to occur. 2 

The imperfect evacuation of the bladder, in cases of stricture, 
and the consequent partial retention and decomposition of the urine, 
maintain the lining membrane in a state of chronic inflammation, 
which manifests itself, as in other mucous tissues, by hypertrophy, 

1 Thompson, The Enlarged Prostate, its Pathology and Treatment, London, 1858, 
p. 58. Adams, The Anatomy and Diseases of the Prostate, London, 1853, p. 46. 
Preparation in George's Hospital Museum, No. S 21. (Thompson.) 



URETERS AND KIDNEYS — GENITAL ORGANS. 259 

abnormal vascularity, increased secretion, and great irritability. 
On post-mortem examination, the mucous membrane of the bladder 
is found to be thickened, soft, and pulpy ; its color is heightened, 
generally of a dark-red hue, and much congested in patches ; its 
surface is smeared with slimy mucus, which, when mingled with 
the urine, may obstruct the narrow orifice of the stricture ; scat- 
tered over it is a quantity of fine calculous matter, or it is covered 
with lymph, sometimes in small patches, at others, in layers of con- 
siderable extent. 

The irritability of the bladder excites to frequent acts of mictu- 
rition, and the capacity of this viscus, never fully distended, is 
eventually much diminished. Instances are recorded in which it 
would not contain more than an ounce, or even half an ounce, of 
fluid. When it has existed any length of time, this condition is 
but very imperfectly remediable, even if the stricture which caused 
it be successfully dilated, .and the patient can never after have due 
control over his bladder. In exceptional cases, a contrary condition 
is produced ; if little or no irritability of the bladder be present, 
the impediment to the flow of urine may cause constant distension 
of this viscus, and its capacity be increased, instead of diminished ; 
in either case its walls are hypertrophied. • 

Ureters and Kidneys. — As a stricture obstructs the exit of urine 
from the bladder, so it cannot but impede the passage of fluid into 
it ; consequently we find changes in the ureters and kidneys simi- 
lar to those already described. The former are often so dilated 
that they will admit the finger or thumb, and, in some instances, 
have been mistaken for a portion of the small intestine ; their pa- 
rietes are thickened, and lymphy deposits, and other evidences of 
chronic inflammation are found upon their internal surface. The 
kidneys may participate in these lesions ; the pelvis, infundibula, 
and calices, are distended ; the medullary tissue of the organ is 
atrophied under the pressure to which it is subjected, and enormous 
reservoirs may be formed, capable of containing five, ten, and, in 
one instance, observed by Mr. Thompson, twenty ounces. 

Genital Organs. — Stricture is not unfrequently attended with 
hypertrophy and induration of the penis, and tumefaction and 
oedema of the prepuce. These lesions cannot be explained in an 
entirely satisfactory manner. Hypertrophy may be accounted for 
in many cases by the traction which patients suffering with stric- 
ture are wont to exercise upon the penis, but this does not explain 



260 STRICTURE OF THE URETHRA. 

the induration ; and, in some instances, both hypertrophy and indu- 
ration are present, when the habit referred to has not been prac- 
tised. A similar condition of the parts is met with in certain 
affections of the prostate and neck of the bladder. Civiale 1 ascribes 
it to prolonged and frequent efforts to urinate, which obstruct the 
venous circulation, and maintain a state of chronic irritation or 
inflammation. The sympathy of the genito-urinary organs, one 
with another, has also, probably, some influence. The tumefaction 
of the prepuce is sometimes sufficient to require scarification. 

The ejaculatory ducts may be dilated ; their walls, and those of 
the vesiculae seminales, inflamed and thickened ; and their cavity 
contain pus, and other products of inflammation. 

There is often considerable irritability of the testicle, and attacks 
of epididymitis sometimes occur, especially after the use of instru- 
ments within the urethra. Yelpeau 2 draws a distinction between 
epididymitis, dependent upon gonorrhoea, and the present form; 
and states that in the latter there is rarely effusion into the tunica 
vaginalis, and that the inflammatory symptoms, which are much 
less severe, usually disappear in five or six days, even without 
treatment. In my own practice, I have not found this difference to 
obtain. One of the most severe and obstinate cases of swelled tes- 
ticle I ever saw, was due to the use of bougies in the treatment of 
stricture ; and I have met with others which have been very far 
removed from the mild character described by Yelpeau. 

Constitutional Effects. — A person laboring under stricture in one 
of its more aggravated forms, is generally subject to more or less 
impairment of the digestive and nutritive organs. His appetite is 
defective ; his digestion imperfectly performed ; his tongue coated ; 
he loses flesh and strength ; has frequent attacks of chilliness, which 
sometimes assume a periodic type; complains of pain and disa- 
greeable sensations in various parts of the body, most frequently 
in the perineum, back, loins, thighs, and often in the sole of the 
foot; he is low-spirited and anxious, and may eventually become a 
confirmed hypochondriac. To understand how stricture can affect 
distant organs, it is only necessary to recall to mind the importance 
of the renal secretion as a depuratory agent of the system; and 
also the intimate connection which exists between the perfect 
working of all parts of the animal economy, whereby any defect 

1 Op. cit., p. 141. 2 Dictionnaire de Med., t. xxix. p. 465. 



SYMPTOMS OF STEICTUBE. 261 

in one is speedily manifested in others. It is evident from a con- 
sideration of the organic lesions which stricture induces in the 
bladder, ureters, and kidneys, that the secretion of urine must be 
seriously interfered with, and the perfect elimination of effete mat- 
ter consequently prevented ; and it is also probable that more or 
less noxious material is absorbed from the partially decomposed 
urine which collects in the bladder and elsewhere. The inevitable 
effect of this upon the system at large, and especially upon the 
nervous centres, is too well known to require explanation. The 
solidarity of the genito-urinary and other organs is nowhere more 
evident than in ophthalmic practice. Instances in which certain 
forms of eye disease, as asthenopia or choroiditis, coexist with, and 
clearly depend upon, an affection of the urethra, vagina, or uterus, 
are so common, that the experienced oculist never fails to inter- 
rogate his patients respecting the condition of the latter organs, 
being convinced that no treatment of the eye disease can be suc- 
cessful, unless these be in a state of health. The same sympathy 
which here exists between the genito-urinary organs and the eye, 
must also extend to other parts of the system. 

SYMPTOMS OF STEICTUKE. 

One of the earliest symptoms of organic stricture is generally a 
gleety discharge from the urethra. If the contraction of the canal 
has immediately succeeded an attack of gonorrhoea, the urethra 
may never have recovered its normal condition since the acute 
symptoms were present; but in some instances all traces of muco- 
purulent matter have entirely disappeared, or at least have not for 
some time attracted the notice of the patient, when suddenly, per- 
haps after some excess, the linen is found again stained, or the lips 
of the meatus adherent. The discharge, under these circumstances, 
may present all the varieties, in respect to character and the time 
of its appearance, already mentioned in connection with gleet. It 
may be constant, and sufficiently copious to soil the linen ; or very 
slight, and only perceptible on rising in the morning. It may be 
aggravated by violent or prolonged exercise, sexual intercourse, 
alcoholic stimulants, or atmospheric changes, and become so abun- 
dant and purulent as to lead to the supposition that a fresh clap has 
been contracted; and though, under favorable circumstances, it 
may nearly or quite disappear for a time, yet it soon returns, and 



262 STRICTURE OF THE URETHRA. 

does not permanently yield to the ordinary treatment of gleet. 
This discharge is not a constant symptom of stricture, bnt is pre- 
sent in the great majority of cases. It is chiefly derived from the 
contracted portion of the canal, and the parts lying directly behind 
it, which are almost invariably the seat of chronic inflammation, 
and are more or less modified in their vitality. 

Another early symptom, and sometimes the first which attracts 
the notice of the patient, is a gradual diminution of the power, 
which, in a state of health, he possesses over the bladder and the 
act of micturition. He is not able to retain his water as long as 
usual, and a desire to urinate calls him up several times during the 
night. He attempts as usual to accomplish the act, when he finds 
that he must wait and make repeated efforts before the urine ap- 
pears; the stream, moreover, is diminished in fulness, is projected 
with less force than natural, and may be variously distorted ; some- 
times it is flattened, at other times, spiral like a corkscrew, forked, 
or divided into two or more portions which diverge from the 
meatus ; or, at the same time that a small stream issues from the 
canal, a portion falls in drops at his feet; he is obliged to take 
special care to avoid soiling his shoes and clothes; and, finally, 
when he supposes the act fully accomplished, a few drops dribble 
away, and wet his person and his clothing. The above symptoms 
cannot be regarded as pathognomonic of organic stricture, since 
they may be produced by other causes, as the presence of inspis- 
sated mucus in the canal, spasmodic contraction, calculi, irregular 
action of the bladder, etc. ; still they are valuable indications, espe- 
cially when persistent, and are generally, though not always, pro- 
portioned to the degree of the coarctation. 

At the same time, each passage of the urine is attended with 
pain and disagreeable sensations, which vary in intensity, position, 
and character. Most frequently there is a sense of dull aching in 
the perineum, back, and loins, or in the glans penis ; often pain of 
a sharper character is felt in the course of the urethra or at the 
neck of the bladder, or follows the course of the spermatic cord, 
and is most severe in the groins and testicles, while sometimes it 
shoots down the thighs. Another frequent seat of pain is behind 
the pubes, where it is probably due to some degree of inflamma- 
tion of the bladder. In short, a condition of morbid sensibility 
exists in the urinary organs, and in the parts connected with them 
either by continuity of tissue or a common nervous supply. 



SYMPTOMS OF STRICTURE. 263 

As the disease progresses, all the above symptoms are aggravated ; 
and the urgency of micturition, especially, is much increased. Fre- 
quently, the patient is almost wholly deprived of sleep by repeated 
calls to urinate, and the length of time which this act requires. 
In aggravated cases, the urine dribbles away in small quantities, 
while the patient is asleep, or without his consciousness during the 
day ; and he is first made aware of its passage by the wetting of 
his person. This has sometimes been mistaken for incontinence of 
urine; whereas it is almost invariably due to distension of the 
contracted bladder and overflow of its contents. The urine also 
undergoes certain changes in consequence of its retention and partial 
decomposition, and the vesical inflammation which is thereby ex- 
cited. It is generally alkaline in its chemical reaction, of an offensive 
odor, cloudy, mixed with slimy tenacious matter which adheres to 
the sides of the vessel, and deposits on cooling a pale precipitate, 
which is found under the microscope to consist of crystals of the 
triple phosphate, epithelium scales, and pus-globules. This con- 
dition of the urine is highly favorable to the deposition of calculous 
matter ; fine sand is often contained in the last portion of urine 
that comes away in micturition, and excites a scalding sensation in 
the urethra ; or calculi are formed, which may be retained in the 
bladder or become impacted in the dilated portion of the canal 
behind the stricture. 

Hsematuria, which, however, is seldom excessive, sometimes 
occurs in connection with stricture, and is most frequently met 
with in old and aggravated cases in which the mucous membrane 
of the urethra is much congested. It chiefly follows the use of 
instruments which have probably wounded some vessel ; or the 
vascular tissues may be ruptured during the turgescence of erec- 
tion; or, again, it may occur without appreciable cause. Some- 
times, also, blood in small quantities is discharged from the mucous 
membrane of the bladder. These two sources of hemorrhage may 
generally be discriminated. If the blood come from the bladder, 
it is uniformly diffused through the urine to which it communicates 
a dark color, or the latter portion of the stream is still more deeply 
tinged and contains broken clots ; frequently, also, there is pain 
and sensibility on deep pressure above the pubes. If it come from 
the urethra, it is found in the form of clots alone, or it may flow 
from the canal independently of the passage of the urine. 

The genital functions may be variously interfered with. In con- 



26-i STRICTUKE OF THE URETHRA. 

sequence of the irritation of the parts, frequent erections may take 
place, or nocturnal emissions occur. In other cases, erection is 
never perfect, owing to the rigidity of the urethra, or an obstruc- 
tion to the entrance of blood into the corpora cavernosa ; pain is 
felt in sexual intercourse ; and the semen, instead of being at once 
ejaculated, slowly dribbles away, or passes backward through the 
dilated urethra into the bladder ; hence, persons with stricture are 
frequently impotent. Civiale remarks that ejaculation is followed 
by a momentary improvement in the power of urinating, but that 
the patient is left in a state of exhaustion, which frequently does 
not disappear for twenty-four hours. 1 

Hemorrhoids, prolapsus ani, and irritation about the rectum, 
which is occasionally severe, are often occasioned by the repeated 
and violent straining required in emptying the bladder, and are 
thus indirectly symptoms of stricture. In a similar manner, hernia 
is liable to occur, especially in old men, and is a source of great 
annoyance, owing to the difficulty of retaining the gut in place. 

Eetention of urine sometimes supervenes in the early stages of 
organic stricture, in consequence of congestion and spasm ; it may 
indeed, in rare instances, afford the first indication to the patient 
that he is the subject of stricture ; but in most cases it appears at 
a later period, when the obstruction to the passage of urine is 
already very great. It generally follows exposure to wet or cold, 
a long ride or drive, and, most frequently, a hearty meal, at which 
alcoholic stimulants have been freely indulged in, the kidneys 
stimulated to excessive secretion, the bladder distended, a tendency 
to congestion induced, and the urine long retained; when, on 
attempting to urinate, the patient finds that he is utterly unable 
to pass water, or only in such small quantities that the bladder is 
not relieved from the internal pressure of its contents. The first 
few attacks of this kind may perhaps be remedied without much 
difficulty by the passage of a catheter, a hot bath, etc. ; and some 
patients, who are subject to retention, learn to relieve themselves, 
and carry an instrument habitually with them for the purpose. 
Sooner or later, however, with the progressive contraction of the 
stricture, an attack of a far more serious character occurs ; former 
means of relief are tried and found inefficient ; the bladder be- 
comes more and more distended, and, unless incapable of dilating 

1 Op. cit., p. 167. 



SYMPTOMS OF STEICTUEE. 265 

through excessive thickening and contraction of its walls, rises 
above the pubes, and forms a tense, ovoid tumor, which may reach 
as high as the umbilicus. The situation of the patient is now 
exceedingly critical ; violent and fruitless efforts are made to uri- 
nate ; pain already felt from the commencement of the attack along 
the course of the urethra, above the pubes, in the perineum, back 
and loins, becomes more general and more intense ; the body is co- 
vered with profuse perspiration and emits a urinous odor ; the face 
is flushed and anxious ; the eyes injected ; the whole aspect of the 
patient is one of terror and despair ; and, unless relief be obtained, 
the scene closes, in a few days, with delirium, coma, and death. 
The suffering induced by severe retention of urine surpasses the 
power of language to depict ; one only who has felt, or often wit- 
nessed it, can fully appreciate the agony. 

Distension of the bladder, in such cases, may even produce rup- 
ture of the vesical Avails. Two cases are reported by Sir Everard 
Home, two by Mr. Thompson, 1 and one in a recent number of the 
Medical Times and Gazette. 2 If the peritoneum be involved in the 
rent, the urine gains entrance to the abdominal cavity ; the vesical 
tumor disappears, but the bowels are generally tense and swollen, 
and death soon occurs from peritonitis. More commonly the peri- 
toneum is spared, and the contents of the bladder are at first effused 
into the sub-serous cellular tissue, where they may cause extensive 
gangrene of the surrounding parts, or whence they may afterwards 
escape into the abdominal cavity by ulceration. In no case of 
rupture of the bladder from retention, has the patient been known 
to recover. 3 

Still more frequently, the distension of the bladder produces 
rupture of the urethra behind the stricture, where its walls are 
weakened by chronic inflammation and ulceration. In the sudden 
and extensive infiltration of urine which ensues, no time is given 
for adhesive inflammation to erect barriers to its progress, as often 
happens in the slower formation of urinary abscesses, and thus the 
urine, forced on by the contractile power of the bladder, permeates 
the loose cellular tissue, wherever it is not limited by the fasciae, 
the influence of which in determining the course of urinary infil- 
trations has already been described. When the rupture takes place 
anteriorly to the triangular ligament, the effusion extends forwards 

1 Op. eit., p. 351. 2 For Feb. 11, 1860. 3 Thompson, op. cit. 



266 STRICTURE OF THE URETHRA. 

and upwards into the scrotum and over the abdomen ; its extent 
may generally be defined by the swelling and discoloration of the 
integument, and an emphysematous crackling on pressure, which 
is due to the mixture of gases with the fluid ; the vascular connec- 
tion between the superficial and deeper tissues is cut off or impeded, 
and, unless free incisions are made, gangrene of extensive portions 
of the skin may ensue. Thus, cases are recorded, in which the 
effusion perforated the superficial perineal fascia and extended 
down upon the thighs, and in which the greater part of the integu- 
ment from the knee to the umbilicus, including the coverings of 
the penis and scrotum, sloughed away, and left the testicles entirely 
exposed, and suspended only by the spermatic cords and vessels ; 
yet, even under these circumstances, recovery has been witnessed. 
"When rupture takes place posteriorly to the triangular ligament, 
the symptoms may for a time be obscure ; as when occurring else- 
where, the patient often has the sensation of something giving way, 
and experiences temporary relief from his sufferings ; if the rent 
be large enough to allow of the free escape of urine, the vesical 
tumor subsides, and, the tension of the parts being relieved, the 
patient may be able to pass water, but the quantity thus evacuated 
or drawn off is found to be small ; soon deep throbbing pain is 
felt in the perineum, and symptoms of general depression set in ; 
and the urine, after burrowing in various directions, may approach 
the surface. A symptom, which is to be regarded as of very 
serious import, is the appearance of a dark spot upon the glans 
penis, which indicates that the infiltration has gained access to the 
corpus spongiosum urethras, and that gangrene has already com- 
menced. 

CAUSES OF STRICTURE. 

A knowledge of the causes of stricture, and the relative fre- 
quency of their action, may best be attained from an analysis of a 
large number of cases, such as is furnished in the following table 
prepared by Mr. Thompson. It should be observed that 143 of 
these 220 cases were collated from the records of University Col- 
lege Hospital, London, and 49 from reports by different surgeons 
in medical journals ; they may, therefore, be regarded as free from 
any preconceived notions as to the etiology of stricture, and in a 
high degree trustworthy ; at the same time, occurring for the most 



CAUSES OF STRICTURE. 267 

part in hospital practice, they represent the worst class of urethral 
contractions. 

ANTECEDENTS, OR SUPPOSED CAUSES OF 220 CASES OF STRICTURE. 1 

Gonorrhoea!. Inflammation in . . . . . . . . . 164 

Injury to Perineum ........... 28 

Cicatrization of Chancres . . . . . . . . ... 3 

Ditto, following Phagedena .......... 1 

Congenital, including cases in which the urethra may have been small from 
malformation, and those in which marked irritability of the urinary 
organs existed from childhood, accompanied by an unusually small 

stream ............. 6 

Poisoning by Nitrate of Potash, 2 Lithotrity, Masturbation, 3 of each one . . 3 
True Inflammatory Stricture, including temporary stricture and retention from 
sudden acute inflammation, usually caused by some excess, and disap- 
pearing by resolution .......... 8 

True Spasmodic Stricture, caused by irritation about the rectum ... 2 

" no cause assignable ...... 2 

" " caused by undue acidity or alkalinity of the urine 3 

220 
Of the 164 cases attributable to gonorrhoea — 

In 90 the disease is reported to have been chronic, or neglected. 
" 3 it was attributed by the patients to strong injections. 
" 6 the discharge is stated to have ceased entirely and rapidly under 
treatment ; but in five of these stricture appeared almost immedi- 
ately after. 
" 4 other cases the stricture appeared to be almost simultaneous with 
the gonorrhoea. 
In the remaining 61 there is no report of chronicity, etc. 

Of the 164 cases attributable to gonorrhoea — 

10 appeared immediately after, or during the attack ; 

71 " within 1 year of its occurrence ; 

41 " within 3 or 4 years ; 

22 " within 7 or 8 years ; 

20 are reported at periods between 8 and 20 to 25 years. 

It appears from the above table that gonorrhoea holds the first, 
and injuries of the perineum the second rank in the etiology of 
stricture ; and this inference is confirmed by the universal expe- 
rience of the profession at the present day. In a treatise on vene- 
real diseases, it will only be necessary to consider the former of 

1 Thompson, op. cit., p. 124. 

2 Medical Times, June 22, 1844. 

3 Lallejiaxd, Clinique Mudico-Chirurgicale, Ire part, p. 109. 



268 STRICTURE OF THE URETHRA. 

these causes, and the minor influence exerted by the cicatrization 
of chancres in the production of stricture. 

I. Commencing with gonorrhoea, let us ascertain, if possible, 
under what phases or circumstances this disease terminates in stric- 
ture. Here, again, Mr. Thompson's statistics accord with the obser- 
vation of every surgeon, that urethral contractions are favored by 
the long continuance, rather than the severity, of urethritis. If we 
omit the 61 cases of the above table in which there is no report of 
the duration of the preceding gonorrhoea, we find that, in nearly 
nine-tenths of the remainder, the urethral inflammation, to which 
the stricture was attributable, was either chronic, or neglected. In- 
quiries addressed to patients laboring under stricture show that, in 
the great majority, the urethral contraction has been preceded by 
several attacks of gonorrhoea ; but, whether by one or more, that 
the last was prolonged for many weeks or months, and terminated 
in a gleet. This coincides with what is observed in other mucous 
canals ; organic contractions of the lachrymal passages, of the oeso- 
phagus and rectum, are rarely, if ever, produced by acute, but 
almost invariably by chronic, inflammation; whatever inflamma- 
tory products are effused in the former are albuminous, and admit 
of ready absorption, while those of the latter are fibrinous, and 
tend to become organized and permanent. . 

This view is also supported by the fact that the most common 
seat of stricture is at a distance of four or five inches from the 
meatus, since gonorrhoeal inflammation during the acute stage is 
usually confined to the neighborhood of the fossa navicularis, while 
gleet affects the deeper portions of the canal, as shown by daily 
experience, and also by the post-mortem examinations of Eoki- 
tansky and Mr. Thompson, who state that they have most frequently 
found the bulb the seat of chronic inflammation. The greater vas- 
cularity of this portion of the canal should be taken into account 
in this connection, since "the amount of inflammatory effusion may 
be assumed to correspond with the amount of blood supplied ;" and 
this will perhaps explain why stricture is not more frequently 
situated in the membranous region. 

If the ground here taken be correct — of which I think there can 
be no doubt — it may be assumed that whatever prolongs the dura- 
tion of gonorrhoea, tends to produce stricture; among the indirect 
causes of stricture, therefore, may be enumerated, a strumous, rheu- 
matic, or gouty diathesis, imprudence in diet, indulgence in coitus, 



CAUSES OF STRICTURE. 269 

prolonged or violent exercise, acidity of the urine, irritability of the 
urethra resulting in repeated spasmodic contractions, etc. The in- 
fluence of all these causes in aggravating urethral inflammation is 
either sufficiently obvious, or has been dwelt upon in the chapter 
upon gonorrhoea, and need only be alluded to at present. 

Laceration of the urethral walls during chordee, and wounds 
from the imprudent use of sounds, catheters, etc., require a passing 
notice. The former may occur spontaneously, or arise from the 
habit, more prevalent among Frenchmen than Americans, of re- 
lieving chordee by forcibly extending the penis; or, as is said, 
"breaking the chordee." Thompson states that he has met with 
an occasional example of stricture originating in this manner ; and, 
judging from the violent hemorrhage which sometimes follows this 
procedure, it may doubtless lacerate the canal to such an extent as 
to produce this effect. "Wounds of the urethra by instruments from 
within evidently have the same effect as from without ; in the pro- 
cess of cicatrization which ensues, the natural coaptation of the 
parts must frequently be lost, and flbro-plastic material endowed 
with contractile properties be deposited. 

The origin of gonorrhoea does not affect its liability to produce 
stricture, except so far as it influences its duration. Urethral con- 
tractions are as likely to follow urethritis occasioned by leucorrhoea, 
the menstrual fluid, acrid vaginal secretions, excess of venery, etc., 
as when the same disease is dependent upon direct contagion. This 
statement is founded not merely upon a belief in the simple nature 
of gonorrhoea, but upon observation ; and there is not, moreover, 
the slightest evidence that the plastic material of stricture (except 
in a class of cases to be mentioned presently) is of a specific charac- 
ter, nor is it influenced by the internal administration of mercury, 
which speedily acts upon the specific induration of secondary sy- 
philis. 

A class of cases is referred to by Mr. Thompson, as of occasional 
occurrence — though less frequent than is commonly supposed — in 
which organic stricture appears at a late period of life, when there 
has been no urethritis for very many years before ; and the ques- 
tion is asked whether any relation exists between the two in the 
way of cause and effect. Mr. Thompson adopts the probable ex- 
planation, that a predisposition to congestion and inflammation may 
remain after an attack of gonorrhoea in youth, and be kept up by 
free habits of living, frequent exposure to atmospheric changes, an 



270 STRICTURE OF THE URETHRA. 

acrid condition of the urine from dyspepsia or gout ; or by other 
causes, and finally result in the slow development of stricture, 
which does not manifest itself until many years after the acute 
attack. 

Much influence in the production of stricture has been attributed 
to the use of injections. I feel obliged to dissent in toto from this 
opinion, which appears to me to be based alone upon reasoning 
post hoc ergo propter hoc. It is asserted in its support, that the 
greater number of patients with stricture have employed injections 
for the preceding gonorrhoea ; but even if this were proved to be 
true by the necessary statistics, it would not be conclusive to 
establish a connection between the two, while injections continue, 
as now, to be the favorite treatment of clap ; it would rather prove 
that stricture follows gonorrhoea, which is incapable of being cured 
by injections. But that the statement referred to is an exaggera- 
tion — at least so far as concerns strong injections — may, I think, be 
fairly inferred from the above table of Mr. Thompson, in which it 
appears that of the 164 cases of stricture attributable to gonorrhoea, 
in only three " was it stated by the patients that they attributed the 
complaint to their use, notwithstanding the disposition which patients 
commonly manifest to refer the cause of their disease to any par- 
ticular mode of treatment, rather than to their own indiscretions, 
while in by far the larger proportion it was stated that their pre- 
vious gonorrhoeas had not been combated by any kind of injec- 
tions." x When made very strong, or used at an improper stage of 
the disease, or with excessive force, they may doubtless act as 
escharotics, or aggravate the inflammatory action, and thus favor 
urethral contraction, but this effect pertains alone to their abuse. 
At the present day, however, this prejudice against injections may 
be regarded as nearly exploded ; the most eminent modern surgeons 
employ them in their practice and highly recommend them, and I 
am happy to quote in their favor so high an authority as Mr. 
Thompson, who would naturally look at the subject from its stric- 
ture aspect, and whose opinion may therefore be regarded as un- 
biassed by any partiality for the use of injections in gonorrhoea. 
This surgeon says: "I have no hesitation in asserting that the 
proper employment of injections is one of the best modes of com- 
bating urethral inflammation, especially in the chronic form, and 
thus of preventing the occurrence of stricture." 

1 Thompson, op. cit., p. 116. 



DIAGNOSIS. 271 

II. A chancre, like any other ulcer, destroys a certain portion of 
the tissues upon which it is situated, and this loss of substance is 
not restored in the process of cicatrization, but the gap is filled 
with fibro-plastic deposit, in the form of granulations, which gradu- 
ally contracts and approximates the edges of the original sore, or 
which forms a hard unyielding cicatrix between them. In this 
manner chancres situated upon any portion of the urethral mucous 
membrane may lay the foundation of stricture. Examples are 
most frequently seen in primary sores upon the margin of the 
meatus, and the more destructive the ulcer, the greater the liability 
of the urethral orifice to become contracted ; hence simple chancres, 
and especially phagedenic chancres, are more to be feared than the 
indurated variety, since the latter, as a general rule, are more super- 
ficial. The same cause of stricture may sometimes be recognized 
within the canal at a greater or less distance from the meatus, and 
it is extremely probable that it exists in other cases which are 
mistaken for simple gonorrhoea, although the discharge is really 
due to a concealed chancre. 

Though an infecting chancre upon the urethral mucous membrane 
may not occasion sufficient loss of substance to produce a stricture 
in the manner now described, yet it possesses another attribute 
capable of effecting the same result. The specific induration 
which underlies it and surrounds it, may destroy the normal elas- 
ticity of the urethral walls and present a serious obstacle to the 
flow of urine, and the introduction of instruments. Several in- 
stances of this kind have been observed by Kicord. 1 In some 
cases, doubtless, a stricture may be due to both these causes com- 
bined, viz., the cicatrix of an excavated ulcer, and specific indura- 
tion. 

DIAGNOSIS. 

The general symptoms alone might be considered sufficient to 
indicate a case of stricture, but in many instances are very deceit- 
ful. There are other affections of the urinary organs, the symptoms 
of which closely resemble those of stricture, and which have often 
been mistaken for it. Experience, therefore, would show that the 
greatest care should always be employed in forming a diagnosis. 
The diseases which are most likely to be confounded with organic 

1 Hunter and Ricord on Venereal, 2d ed., Phil. 1859, p. 172. 



* 



272 STRICTURE OF THE URETHRA. 

stricture, are subacute inflammation of the prostate, and urethral 
neuralgia and hyperesthesia, which have received due attention in 
other chapters of this work. I merely desire at present to glance 
at a few important points. 

Subacute inflammation of the prostate may be attended by 
nearly every symptom, which has been described as belonging to 
stricture, viz., by frequency and difficulty of micturition, gleety 
discharge, and pain in the perineum, above the pubes, and elsewhere. 
This identity in the symptoms may readily lead to a mistake in 
diagnosis, which may even be confirmed by a superficial explora- 
tion of the urethra ; for the prostatic portion of the canal, in this 
affection, is exceedingly sensitive and the introduction of a catheter 
attended with severe pain ; if, then, the surgeon yields to the feel- 
ings of the patient and fails to make a thorough examination, or, 
if he employs a fine sound or bougie, the point of which is liable 
to be obstructed by catching in some lacuna of the mucous mem- 
brane, the erroneous conclusions already drawn from the history 
of the case, may apparently be confirmed. 

The same mistake may also occur in cases of urethral hyperes- 
thesia, either when occasioned by sympathetic irritation from stone 
in the bladder, affections of the rectum, etc., or when, in the absence 
of any apparent cause, the exalted sensibility can only be attri- 
buted to nervous derangement. The diagnosis of a suspected case 
of stricture can, therefore, only be founded upon a careful and 
thorough exploration of the urethra, and the instruments required 
in such examination, and the manner of using them, will now 
claim our attention. 

Exploration of the Urethra. — The instruments requisite for phy- 
sical exploration of the urethra and the diagnosis of stricture are 
a set of catheters or sounds — and preferably both — ranging from 
ISTo. l.to No. 12 or 15 of the catheter scale in ordinary use; a good 
supply of gum-elastic bougies, and several sounds with bulbous 
points. 

Catheters are best constructed of virgin silver, which permits of 
their being bent to any desired curve. They are conveniently 
made somewhat longer than the canal they are designed to traverse, 
and usually measure about eleven inches. The surgeon should 
possess a prostatic catheter which is at least fifteen inches in length. 
The handle of the catheter is provided with a firm oval ring attached 



EXPLORATION OF THE URETHRA, 



273 



to each side, in order that the least twisting of the instrument on 
its axis after its introduction may be at once manifest to the oper- 
ator; and also to permit of its being retained as a permanent 
catheter. The vesical extremity of the instrument has two eyes 
for the escape of urine, one situated half an inch, and the opposite 
one an inch from the extremity. They are often made too large, 
and allow of the protrusion of folds of the lining membrane of the 
canal, obstructing the passage of the catheter, and exciting un- 
necessary pain. Their edges should be bevelled off with nicety. 
Instead of these two lateral eyes, the end of the catheter is some- 
times pierced with numerous small apertures, which are objection- 
able on account of their liability to become clogged with blood or 
mucus, 

The degree of curvature of this and other instruments used in 
urethral exploration is a matter of no small importance. It would 
seem desirable that the curve should correspond to the natural 
curvature of the least movable portion of the urethra itself, which 
is that portion underlying the symphysis pubis. Mr. Thompson 
has adopted this principle in the construction of catheters, and his 
example has of late been very generally followed, since it has been 
found that experience confirms the deductions from theory, and that 
urethral instruments with such a curvature are most readily intro- 



Fig. 16. 




duced. When speaking of the anatomy of the urethra, the sub- 
pubic curve was described as an arc of a circle three and a quarter 
inches in diameter, the chord of the arc measuring two inches and 
18 



274 STRICTURE OF THE URETHRA. 

three -quarters. The accompanying figure from Mr. Thompson 
exhibits a catheter and sound so bent as to correspond to this curve. 

In order that the precise direction of the point of the instrument 
may be indicated by the direction of its shaft, it is desirable that a 
constant relationship should exist between the two. According to 
the principle of construction here recommended, this is a right 
angle in the catheter, and in the sound, a somewhat shorter instru- 
ment, an angle of 120°, or a right angle and a third. 

It is desirable to have one or more catheters graduated in inches 
and fractions of an inch, in order to measure the depth at which 
strictures are situated, and to determine the length of the urethra; 
when used for the latter purpose, the graduation should commence 
with the terminal opening and not from the extreme point. 

Gum-elastic catheters, which may be rendered stiff by a stylet, 
are sometimes used, but are not so generally applicable as those of 
silver. 

Sounds of solid silver are the best, but too expensive. They are 
generally made of steel, which should be pure and highly polished, 
to avoid the action of rust. To answer this requisite they are 
sometimes silver plated, but this does not afford reliable protection, 
and it is better that they should be " polished in oil" rather than 
burnished. The handles of sounds should be broad and roughened, 
so as to afford a firm hold to the hand, and indicate any deviation 
in the direction of the point. As sounds are not intended to enter 
the bladder, except for the occasional purpose of ascertaining the 
presence of stone, they may be half an inch shorter than catheters, 
but should follow the same curve. 

Bougies are made of wax, whalebone, elastic gum, and other 
materials, and terminate at the extremity in a blunt, conical, fusi- 
form, or olive-shaped point. Gum-elastic bougies are generally 
preferable, except for very narrow strictures, where those of catgut 
or whalebone are employed, as firmer and less liable to bend or 
break. In the absence of other kinds, the surgeon may manufac- 
ture wax bougies by soaking a piece of fine linen, of suitable length 
and width, in melted wax, and afterwards rolling it upon a hard 
surface into a cylinder. Bougies thus constructed are especially 
convenient for applying caustics to strictures. 

A twisted or corkscrew form may be imparted to the extremity 
of a bougie by winding it round a wire and retaining it in place 
for a few moments. This form is of great value when the opening 



BULBOUS SOUNDS. 275 

in the stricture is at one side of the centre of the canal. It was 
first recommended by Leroy d'Etiolles, 1 and whalebone bougies 
of this shape are always employed by Dr. Phillips in difficult 
cases. 

I am partial to olive-pointed bougies, which are introduced with 
great ease and freedom from pain, a matter of some importance 
with nervous patients, or when the urethra is very sensitive. The 
contraction posterior to the olive-shaped extremity is also well 
adapted to carry to the deeper portions of the canal any lubricating 
or medicinal substance with which the bougie is smeared. 

All bougies, and especially those made of fragile materials, should 
be carefully examined from time to time, and if found impaired in 
the slightest degree should at once be destroyed, lest they be in- 
cautiously used and a portion break off in the canal. Bougies of 
elastic gum become rough with use, whereby they irritate the 
mucous membrane, and should, in this case, also be discarded. 
Whalebone bougies must be oiled occasionally, or they become 
brittle and unsafe. 

Bulbous sounds, made of steel, are serviceable in determining the 
extent of a stricture from before backwards, and also in ascertain- 
ing if a second stricture exists posterior to one already discovered. 
It is desirable to have several of them on hand, with the diameters 
of the bulbs varying from Nos. 1 to 6 of the catheter scale. At 
the suggestion of Dr. Geo. A. Peters, of this city, Messrs. Tiemann 
and Co. have recently manufactured a bulbous sound with a fine 
stem upon which bulbs of different sizes may be screwed. The 
staff should be graduated in inches, commencing with the upper 
surface of the bulb, which is abrupt in this direction. The dis- 
tance of the anterior edge of the stricture from the meatus having 
been measured upon a graduated catheter, a bulbous sound is passed 
through the contraction, when the position of its posterior edge can 
be determined by the bulb catching upon it in a to-and-fro motion 
imparted to the instrument ; the difference in the readings upon the 
catheter and sound at a point corresponding to the external orifice 
of the canal will clearly indicate the length of the stricture. This 
measurement is always desirable to aid in determining the probable 
duration of treatment, and is almost indispensable when external 

1 Sur les Avantages des Bougies Tortillees et Crochnes dans les Retrecissements 
et Angusties de l'Uretre difficiles a franchir, Paris, 1852. 



276 



STRICTURE OF THE URETHRA, 



or internal incisions are employed. Again, the small size of the 
shaft gives to bulbous sounds, when passed through one contrac- 
tion, considerable freedom of motion, and enables the operator to 
explore for strictures more deeply situated. 

Bulbous bougies of gum elastic can be introduced with less pain 
to the patient than bulbous sounds, and are, therefore, to be pre- 
ferred, especially for exploring the deeper portions of the canal. 
These and knotted bougies ("bougies a noeuds") are very valuable 

Fig. 17. 




Bulbous and knotted bougies.* (After Phillips. ) 

instruments for detecting a slight degree of contraction, and for 
determining the comparative sensibility of the different portions of 
the urethra. 

Introduction of the Catheter. — A catheter may be introduced while 
the patient is in the standing or sitting posture, but the recum- 
bent position is on many accounts the best; the patient lying 
square on the back, with the shoulders elevated, the knees drawn 
up and somewhat separated, the genital organs entirely exposed, 
and the surgeon standing or sitting on his left. The operator now 
raises the penis to an angle of about sixty degrees with the body, 
thereby effacing the anterior curve of the urethra, by means of the 
ring and middle finger of the left hand, its palm looking upwards ; 
the thumb and forefinger are thus left free to retract the prepuce 
and separate the lips of the meatus. The catheter, previously 
warmed and oiled, is held lightly between the thumb and fore and 
middle fingers of the right hand, "like a pen," its shaft correspond- 
ing to the fold between the abdomen and the left thigh. The in- 
troduction of the instrument should be slow, and with the exercise 
of but very little force ; its own weight is almost sufficient to effect 
its passage if properly directed ; if any obstruction be met with, 
the instrument should be withdrawn for a short distance and again 



1 These instruments may be obtained of Mr. Geo. Tiemann, 63 Chatham St., N. Y. 



INTRODUCTION OF THE CATHETER. 277 

advanced with the direction of its point slightly varied ; or if the 
obstacle be due to spasmodic contraction of the urethra, it may 
generally be overcome by gentle pressure continued for a moment 
or two ; while passing through the first two inches of the urethra 
the point of the instrument is inclined to the lower surface in order 
to aVoid the lacuna magna; beyond this it should be directed rather 
to the upper surface to escape the sinus of the bulb ; when it has 
penetrated beneath the pubis, the shaft is brought round to the 
median line of the body and parallel to the surface of the abdomen; 
the handle is now to be elevated to a perpendicular and then de- 
pressed between the thighs, when the point will usually glide into 
the bladder ; if any difficulty is met with at this stage of the proceed- 
ing, it is probably because the point has caught in the extensible 
tissue of the bulb, and the instrument should be again raised to a 
perpendicular and slightly withdrawn, and the penis elongated by 
traction before the manoeuvre is repeated ; further assistance may 
be obtained, if necessary, during the latter part of the introduction, 
by gently pressing against the convexity of the instrument in front 
of the anus or by introducing a finger into the rectum, ascertaining 
the exact position of the point and guiding it forwards and upwards 
against the posterior surface of the symphysis ; the passage of the 
extremity over the uvula vesicae is often indicated by nausea or a 
slight tremor on the part of the patient, and its entrance into the 
bladder by a flow of urine. 

Let us review these several steps, and notice the chief natural 
obstacles which are to be avoided. The first is the lacuna magna 
situated upon the upper surface of the urethra; this is to be 
shunned by directing the point towards the lower surface during 
the first two inches of its passage. The second is the symphysis 
pubis, against which the extremity of the instrument will impinge, 
if the abdomen be distended and the handle be held in the median 
line ; hence the direction to hold the shaft parallel to the fold of 
the thigh, and not to bring it to the median line or elevate it until 
the point has penetrated beneath the symphysis. The third is the 
sinus of the bulb ; the urethral wall is here very extensible, and is 
readily thrown into a fold upon which the point of the instrument 
catches instead of passing through the opening in the triangular 
ligament into the membranous portion; this is less likely to happen 
if the tissues be stretched by traction upon the penis ; and, if it 
occur, the point is to be disengaged by slightly withdrawing it, 



278 STRICTURE OF THE URETHRA. 

and afterwards advanced in a direction more towards the upper 
surface of the canal. It is to be observed that this is the only 
stage of the process in which traction upon the penis is desirable ; 
after the point has entered the membranous portion, it is positively 
injurious. Again, hypertrophy of the prostate or abnormal de- 
velopment of the uvula vesicas may oppose an instrument in the 
last part of its passage ; this is to be avoided by depressing the 
handle and thus elevating the point towards the symphysis: in 
these cases a prostatic catheter is often required. 

It is a golden rule in every case of suspected stricture to make 
the first examination with a catheter sufficiently large to distend 
the urethra, whatever history of his previous symptoms may be 
furnished by the patient ; in this manner many sources of error 
already indicated will be avoided. The difference in the impres- 
sion conveyed to the hand of the operator by mere spasmodic 
contraction of the urethra and an organic stricture, is very 
marked, but can be better felt than described. In the former case, 
the tissues against which the point of the instrument impinges 
evidently preserve their natural suppleness, and the obstruction 
yields to gentle and continued pressure ; while in the latter, a firm 
resilient obstacle is felt, which can be thrust backwards, imparting 
more or less motion to all the surrounding parts ; and if, after a 
trial of one or more smaller instruments, one be found which can 
be successfully introduced within the stricture, it is grasped or 
"held" by it in a very characteristic manner. The only phenome- 
non that at all resembles this, is contraction of the voluntary and 
involuntary muscles which surround the membranous portion of 
the urethra, and which are sometimes called into action, especially 
in irritable subjects, by the presence of a foreign body; but in this 
case a full-sized instrument can still be introduced with but slight 
difficulty ; and, if allowed to remain a short time, the obstruction 
yields, and the catheter or sound is found to be freely movable. 
Attention to these circumstances will facilitate the diagnosis even 
if the hand be not educated to distinguish the palpable difference 
in the sensations. 

Model Bougies. — Information of value in some cases with regard 
to the size and shape of strictures may be obtained from impres- 
sions taken upon bougies of wax or other plastic material. Dr. 
Henry J. Bigelow, Surgeon to the Mass. General Hospital, highly 



MODEL BOUGIES. 279 

recommends gutta-percha bougies for this purpose. 1 While house- 
surgeon of this hospital in 1850, I had frequent opportunities of 
seeing and assisting Dr. Bigelow in taking impressions by this 
method. The bougies are first prepared by cutting strips approxi- 
mating to the size desired from a sheet of gutta percha ; they are 
then slightly softened by momentary immersion in hot water, and 
rolled smooth between two boards, when they may be at once hard- 
ened again by dipping them in cold water. From a number thus 
prepared, one should be selected which will moderately distend the 
urethra ; it is then to be well oiled, and its extremity softened by 
passing it to and fro over the flame of a spirit lamp or candle ; the 
material will continue plastic after it has ceased to be hot, when 
the bougie is to be passed rapidly down to the obstruction, firmly 
pressed against it for a moment, left in place a short time longer 
to cool, and then slowly and gently withdrawn. The tip will be 
found to bear an impress of the anterior surface of the stricture 
and a portion of the canal within it, and will exhibit the position 
of the obstruction, the size and eccentricity of the opening, etc. ; 
this may be cut off and preserved for future reference, or for com- 
parison with casts subsequently taken. Mr. Thompson 2 objects to 
this procedure on the ground that in a number of instances a por- 
tion of the bougie has been left in the urethra, and has required 
an operation for its removal ; " of which four cases are reported in 
the Dublin Medical Gazette, Jan. 24, 1855." Judging from my own 
experience, I do not believe this accident is liable to occur with 
due caution on the part of the surgeon. The gutta percha should 
be pure and freshly prepared, and its strength can readily be tested 
at the time it is used ; when old it becomes very friable. I have 
before me some bougies which I made ten years ago, and which 
are now nearly as brittle as glass, but I have never seen any ap- 
proach to an accident, when the material was fresh and prepared 
in the manner here directed. I would suggest another caution, 
which is, that the tenacity of gutta percha becomes impaired by 
frequent contact with the urine, and that bougies of this substance 
should not be repeatedly used. It may be observed that the " vul- 
canized rubber," which is now so extensively employed for various 
purposes, may be softened over a lamp in a similar manner, and 

1 Boston Medical and Surgical Journal, Feb. 7, 1849. 

2 Op. cit., p. 188. 



280 STRICTURE OF THE URETHRA. 

would probably make excellent " model bougies." Impressions by 
means of these instruments often afford useful and interesting infor- 
mation, especially in cases complicated with, false passages, but they 
are not to be regarded as generally necessary. 

Strictures of the urethra anterior to the scrotum are often ap- 
preciable from the surface in consequence of the amount of firm 
deposit which surrounds them ; and external as well as internal 
examination is always desirable in order to ascertain the presence 
of any sinus or abscess in the neighborhood of the canal. 



TKEATMENT. 

Constitutional Means. — It is of paramount importance in the 
treatment of stricture not to lose sight of the general condition of 
the system, and particularly of the digestive organs ; indeed, with- 
out this, local measures, however well directed, will either be 
greatly obstructed in their action, or will utterly fail to produce 
any good result. The necessarily injurious influence of even slight 
irregularity of life continued from day to day, may be inferred 
from a consideration of the disastrous effects which may be produced 
by a single excess in wine, exercise, or coitus ; if a few glasses of 
punch, a hearty dinner, or a ride on horseback can occasion 
urethral congestion and spasm, and consequent retention of urine, 
it is reasonable to suppose that even moderate indulgence may 
seriously interfere with any attempt to cure the disease. These 
deductions from theory are borne out in daily practice, and it is 
found to be true as a general rule that the more regular the patient's 
life, the more amenable is his case to treatment. 

The constitutional management of stricture must of course vary 
in different cases. Unless the disease be far advanced, it is generally 
sufficient to prescribe such measures as will best promote the health, 
and place the system in the most favorable condition for absorption 
to take place. Another indication of the highest importance is to 
lighten the duty imposed upon the kidneys, and render the urine 
bland and unirritating to the inflamed surfaces over which it 
passes ; and this is to be chiefly accomplished by regulating the 
character and quantity of food, and favoring depuration of the 
blood through other channels, as the skin, bowels, and lungs. The 
diet should be simple but sufficiently nourishing ; alcoholic stimu- 



TREATMENT— CONSTITUTIONAL MEANS. 281 

lants, highly seasoned food ; cheese, cabbage, salt meats, strong 
coffee, and all articles which tend to load the urine should be 
avoided, as also tobacco — unless in great moderation ; the bowels 
should be opened daily, if necessary, by gentle laxatives, but 
violent purges are to be avoided. The skin should be stimulated 
by frequent bathing and friction ; when there is much irritability 
of the urethra, the hot hip-bath will be found very beneficial ; no 
more exercise should be taken than is sufficient to maintain the 
appetite and strength ; and, in general, the patient should lead a 
quiet and regular life. When the urine is alkaline, or contains an 
undue quantity of lateritious deposit, great benefit will be derived 
from the compounds of potash and soda with the vegetable acids, 
as the citrate and acetate of potash, the tartrate of soda and potash, 
etc. Mr. Thompson recommends benzoic acid in these cases. 

In the more severe cases of stricture, especially when the patient 
has suffered from one or more attacks of retention of urine, it is 
desirable to confine him to the house or even to the bed for a week 
or fortnight before commencing direct treatment ; and this course 
becomes necessary when it is proposed to resort to external or in- 
ternal incisions, or to rapid dilatation. 

Some advantage might perhaps be derived from the administra- 
tion of iodide of potassium, which, when given in the thirtieth 
dilution, is capable, according to the statement of some homoeopaths, 
of curing all cases of stricture (!); but, so far as I am aware, there 
is at present no reliable evidence that this or any other article of 
the Materia Medica can effect absorption of the adventitious depo- 
sit of urethral obstructions. 1 

Probably no class of affections has more thoroughly taxed the 
ingenuity of surgeons to discover some speedy and effectual method 
of cure, than have strictures; and a volume, the size of the present 
one, might be filled with the different operative procedures which 
have been proposed for this purpose ; but the limits of this chap- 
ter require that I should confine myself to the strictly practical, 
and dilate on those methods only which have stood the test of time, 
and which are generally adopted by the soundest surgeons of the 

1 Since the above was written, I have noticed a statement by Dr. Thielman, to 
the effect that he has successfully treated twenty-seven cases of stricture by iodide 
of potassium alone in doses of two and a half grains three times a day. New 
Jersey Medical and Surgical Reporter, Jan. 1858, from the Medical Gazette of Rus- 
sia, 1857. This statement requires confirmation. 



282 STRICTURE OF THE URETHRA. 

present day ; but few of the many which, though extolled for a 
short period, have soon sunk into forgetfulness, will receive even 
a passing notice. 

Dilatation. — From a very early period in the history of sur- 
gery dilatation has held, as it continues to hold, the first place in 
the treatment of stricture. Unassisted by other measures, it is 
able to overcome the larger number of urethral contractions ; and, 
when other methods are employed, it is still required to complete 
and give permanency to the cure. Dilatation may therefore be 
regarded as an essential element of all treatment ; and the greater 
the importance attached to it by the surgeon, the more satisfactory 
will be the results attained in practice. The reason of this pre- 
eminence is to be found in the fact that dilatation accomplishes more 
perfectly than any other method the removal of the fibro-plastic 
material which constitutes stricture. Numerous explanations have 
been given of its mode of action, but the one now generally 
received, and which is unquestionably correct, is, that, so far as it 
effects any permanently good result, it acts by promoting absorp- 
tion. The presence of a bougie within a stricture may mechani- 
cally dilate its walls, but sooner or later after the withdrawal of 
the instrument, the plastic material again contracts; and all the 
phenomena attendant upon dilatation show that it accomplishes 
something more than this, and that, like pressure upon external 
tumors, it possesses the power of producing absorption of inflam- 
matory deposits. At an early period of the existence of stricture, 
before its constituent elements have become firmly organized, there 
is reason to believe that they may be entirely removed by the 
treatment now under consideration ; at a later stage, a portion only 
can be thus dissipated, and it is in these cases that we are forced 
to be content with palliating the evil by mechanically enlarging 
the canal from time to time, or, when the contraction is so firm as 
not to admit of this, by incising the obstruction and afterwards 
stretching the recent fibrinous deposit which forms between the 
edges of the wound. 

The instrument employed in dilatation, whether a catheter, sound, 
or bougie, is in most instances a matter o£ but small importance, 
as may be inferred from the great diversity in the preferences of 
different surgeons, though the weight of authority is probably in 
favor of a metallic instrument. Every operator will generally use 



DILATATION. 283 

that one most successfully to which he is most accustomed ; "but 
there are certain cases in which each possesses peculiar advantages. 
Thus the unyielding material of metallic instruments gives them 
the preference in firm, indurated strictures which are liable to 
indent the softer substance of flexible bougies; moreover, being 
inflexible, they are entirely under the control of the operator, and 
can be guided with precision in any desired direction ; in all cases 
complicated with false passages they should undoubtedly be pre- 
ferred. Their disadvantages are a liability in unskilful hands of 
doing injury to the urethral walls ; the terror which they inspire in 
timid patients, and their inability to adapt themselves to the flexures 
of the canal, whence their introduction is attended with somewhat 
more uneasiness than flexible bougies. Granting, however, the 
possession of that amount of anatomical knowledge, patience, and 
delicacy of touch, which alone can justify any one in performing 
catheterism, there is no serious objection to their employment ; but 
flexible bougies are far safer in the hands of those not endowed 
with these necessary qualifications. 

Especially in the first examination of any case, no instrument 
equals in value the ordinary silver catheter ; its entrance into the 
bladder is surely indicated by the flow of urine through the tube, 
and its blunt point accurately defines the position of any obstruc- 
tion. Sounds or catheters when used for the purpose of dilatation, 
may be slightly conical at the extremity, as this form corresponds 
to the opening of most strictures and facilitates the introduction of 
instruments. "When the canal has once been explored and the 
position and character of the stricture determined, I am in the 
habit of using olive-pointed bougies, the bulbous extremity of 
which prevents any obstruction from the mucous lacunae, while the 
conical form of the shaft above affords the advantages of several 
bougies of different sizes in one, without the necessity of repeated 
introduction. In a few rare cases of tortuous and contracted 
strictures it is impossible to pass any instrument except a filiform 
bougie, which is preferably made of whalebone or of gum elastic. 

The same method should be followed in performing dilatation as 
in ordinary catheterism. If the first instrument employed will not 
enter the obstruction, a second and smaller one must be tried ; the 
dimensions of the stream of urine indicating by approximation 
the actual size required. All attempts to penetrate the narrowed 
channel should be made with the utmost gentleness, and any sud- 



284: STRICTUKE OF THE UKETHKA. 

den thrusting of the instrument especially avoided ; force is only 
admissible when the point is felt to be "held," thereby indicating 
that it is already engaged in the passage, and even then pressure 
must be steady, only very gradually increased, and always moderate. 
False passages are usually found below or at the sides of the ure- 
thra; hence, if there be any reason to suspect their presence, the 
extremity of the catheter should be carefully guided along the 
upper surface. It often happens, however, that the orifice of the 
stricture is eccentric, being above or below, or to one side of the 
centre of the canal ; if therefore previous attempts have proved 
unsuccessful, the direction of the instrument may be varied ; or, 
if a bougie be used, it may be twisted on its axis at the same time 
that it is gently pressed forwards. Assistance is sometimes afforded, 
especially in strictures of the spongy and bulbous portions, by 
passing the disengaged hand down to the seat of the obstruction 
and exercising a certain degree of pressure externally. In cases 
of extreme difficulty, Mr. Thompson 1 recommends that the urethra 
should first be freely injected with olive oil, which is to be retained 
by compression of the meatus while a small instrument is passed ; 
he believes that thus the stricture is not only thoroughly lubricated, 
but also somewhat dilated by the mechanical pressure of the fluid, 
and states that this method has proved of very decided advantage 
in his hands. 

The length of time that the instrument should be retained will 
depend somewhat upon the sensitiveness of the canal ; although 
here I think a distinction should be made between sensibility 
attendant upon inflammation and that which is chiefly nervous, 
the former will be aggravated by the prolonged contact of a foreign 
body, the latter diminished ; as photophobia is in many cases relieved 
by gradually accustoming the eye to light, so there is no more 
effectual remedy for nervous irritability of the urethra than the 
introduction and temporary retention of a catheter, and attention 
to the circumstances of the case will enable the * surgeon to apply 
these principles to practice. As a general rule five minutes is 
sufficiently long for the first session, and the period may gradually 
be extended at subsequent visits to half an hour or an hour. 

The phenomena following the passage of an instrument through 
a stricture have been carefully studied by Mr. Thompson, and are 

1 Op. cit., p. 179. 



DILATATION. 285 

both, highly interesting and instructive. At the first succeeding 
act of micturition, the stream of urine is found to be increased in 
size ; in the course of a few hours it diminishes, and is even smaller 
than before the introduction of the instrument ; finally, after a day 
or two, it is permanently enlarged. Mr. Thompson attributes the 
first mentioned effect to mechanical dilatation ; the second to reac- 
tive congestion and spasm ; and the third to the subsidence of the 
latter, and to the removal by absorption of a portion of the organic 
deposit. The practical deductions from these observations are : 
that an instrument should not be inserted with such force, nor re- 
tained so long, as to excite decided inflammatory action ; and that 
catheterism should not be. repeated until all irritation produced 
by previous applications has disappeared. 1 

An interval of from three to five days between the applications 
is usually sufficient. At the second visit, the instrument first em- 
ployed may be introduced for a moment, then withdrawn, and the 
next larger size inserted. With very irritable strictures, it is often 
advantageous to proceed even more slowly than the ordinary 
catheter scale admits ; that is, by instruments intermediate in size 
between the numbers upon this scale, such as may be found in most 
collections of bougies. For this reason, the more minute division 
of # the French scale, which is divided into thirds of a millimetre, 
is an improvement upon the English. 

Thus, by a gradual advance, the passage may be enlarged to a 
calibre corresponding with that of the external meatus, and although 
this degree of dilatation is usually sufficient, yet it is sometimes 
desirable to exceed it and to restore the constricted portion of the 
canal to its original diameter, which can only be done after incision 
of the unyielding meatus. This is especially advisable in strictures 
attended by frequent attacks of retention, and which speedily re- 
lapse after the cessation of treatment, since it is found that free 
dilatation with instruments carried in some instances as high as No. 
15 or 16, renders the cure much more permanent. Under no cir- 
cumstances should catheterism be at once abandoned so soon as the 
stricture is dilated to the desired extent, whatever that may be ; 
but instruments should be passed at gradually increasing intervals, 
as, for instance, once a week for a short period, then once a fort- 
night, and so on, until several months have elapsed. 

1 Thompson, op. cit., p. 210 et seq. 



286 STRICTURE OF THE URETHRA. 

Some strictures prove impermeable on the first trial, and if, after 
continuing the attempt as long as appears justifiable, success be not 
attained, it is better to defer farther efforts until a subsequent visit. 
Attention has already been called to the fact that those surgeons 
who, like Dr. Phillips, have acquired a reputation for their power 
in overcoming apparently impassable strictures, attain success as 
much by their repeated trials and dogged perseverance as by their 
skill. In cases of " impermeable stricture," especially when attended 
with much sensibility and spasmodic contraction of the urethra, 
great advantage will be derived from placing the patient under the 
influence of an anaesthetic, but the condition of insensibility must 
not be abused to employ more force than would, under other 
circumstances, be justifiable. Pressure against the face of a stric- 
ture, steadily continued for ten or fifteen minutes, and repeated if 
necessary on several occasions, will sometimes prove successful, 
after an attempt to insinuate the instrument within the passage 
has failed ; but care should be taken that its point is really directed 
against the contraction and not upon the urethral wall in the neigh- 
borhood. Excepting those cases in which retention of urine 
demands immediate evacuation of the bladder, and where no op- 
portunity is afforded for making repeated and persevering attempts 
at catheterism, the surgeon will meet with but few strictures which 
he cannot ultimately succeed in overcoming by the dilating pro- 
cess. 

The eminent success of Dr. Phillips in performing catheterism 
in difficult cases of stricture, justifies a few words in explanation 
of his mode of procedure. This surgeon believes with Leroy 
d'Etiolles that the chief difficulty lies in the eccentric position of the 
orifice, and hence in the advantage of using twisted bougies. 
Bougies of gum elastic, however, will not answer the purpose, 
since they are speedily softened by the heat and moisture of the 
canal, and consequently lose their shape, become bent, and present 
too little resistance to overcome muscular contraction. Whalebone 
bougies are free from these objections, and will preserve a spiral 
form for any length of time after their introduction. Believing that 
the difficulty in introducing a filiform bougie is increased when 
the patient is lying down, Dr. Phillips always places him in a 
standing posture against the wall. He then slowly passes the 
bougie as far as the stricture, and gently twists it on its axis, with- 
out any to-and-fro motion, until its point enters the passage. The 



CONTINUOUS DILATATION. 287 

partial faintness which often ensues is regarded as highly conducive 
to success by relaxing muscular contraction ; and its occurrence, if 
not spontaneous, is favored by the administration of small but re- 
peated doses of an emetic, which is thus made to take the place of 
anaesthesia, the latter of course being inadmissible while the patient 
is standing. 

Continuous Dilatation? — A more expeditious mode of dilating 
stricture is by the method known as " continuous dilatation," in 
which the catheter is retained for a considerable length of time, 
generally for several days in succession. In the course of twenty- 
four or forty-eight hours, a purulent discharge appears, proceeding 
from the abraded or ulcerated mucous membrane at the seat of the 
obstruction, and the passage is rapidly enlarged. 

This method is employed by some surgeons in all cases of pas- 
sable stricture, but such practice is not commendable, since it is 
less effective than gradual dilatation in removing the organized 
material constituting the obstruction ; is more likely to be attended 
by untoward symptoms ; and is followed by a strong tendency to 
recontraction. But although continuous dilatation should be re- 
jected as an exclusive method of treatment, it is extremely valuable, 
under certain circumstances, as a temporary resort, and as pre- 
paratory to the intermittent use of instruments. It is advisable : 
1st, when time is of great importance, as with persons from a dis- 
tance or with seafaring men, for whom much may be accomplished 
in a few days, and the after-treatment be left to the patient, in- 
structed in passing an instrument upon himself; 2d, when, in nar- 
row strictures or in those complicated with false passages, great 
difficulty has been experienced in introducing the catheter, and 
fears are entertained that it cannot be reinserted if once withdrawn ; 
and 3d, when it is found impossible to repeat catheterism except at 
long intervals, either in consequence of extreme irritability of the 
urethra, or of rigors following each application. The latter often 
attend the first succeeding act of micturition, and appear to be due 
to the contact of urine with the abraded mucous membrane. 

In either of the above cases if a catheter can be introduced 
through the stricture, it may be retained in place by tapes passed 
through its rings and attached before and behind to a bandage 
around the abdomen ; its point should not be allowed to project 

1 " Dilatation permanente" of the French. 



288 STRICTURE OF THE URETHRA. 

into the bladder sufficiently to injure the vesical coats ; its external 
orifice should be connected with a urinal or fitted with a plug which 
can be removed whenever a desire is felt to urinate, and the patient 
should be confined to the bed. Considerable pain and other un- 
pleasant symptoms are often experienced within a few hours, but 
unless these be severe the catheter should not be withdrawn, and the 
object in view be thereby defeated. The strength should be sup- 
ported by nutritious diet or even stimulants ; pain may be allevi- 
ated by opiates given by the mouth, or preferably, in the form of 
suppositories, and rigors may be met by hot applications to the 
surface, and opium internally. The occurrence of fits of shivering 
for the first time after the catheter has remained in for several 
hours, or the appearance of considerable blood in the urine, are 
indications that the instrument should be at once withdrawn, and 
treatment suspended for a few days. 1 

In most cases, the catheter may be retained for twenty-four to 
forty-eight hours, not longer, lest it become incrusted with calculous 
deposit, or ulceration of the urethral walls be induced ; the patient 
is then allowed to rest for a day or two, and a larger one inserted. 
After several such applications, the urethra will generally be suffi- 
ciently dilated to admit a No. 8 or 10 instrument without difficulty, 
but the treatment must not be allowed to rest here; there still 
remains a strong tendency to contraction, which must be overcome 
by frequent catheterism repeated at first every day or two, and 
subsequently at increasing intervals, as after gradual dilatation ; by 
this means only can it be hoped to maintain the ground already 
gained, and to effect the removal of the contractile material which 
induces relapse. 

Rapid Dilatation. — Continuous dilatation above described, is also 
in a measure rapid, but it accomplishes its object indirectly, while 
the methods we are now briefly to consider aim directly at the 
speedy enlargement of the passage. It is to be distinctly under- 
stood at the outset that these methods are not recommended for 
general adoption ; indeed they would not be referred to at all in the 
limited space we have allotted to this subject, were it not for a few 
exceptional cases in which it is believed they may prove of value. 
Even in gradual dilatation, if the surgeon attempt to advance too 
speedily so much irritation and pain are often excited that it becomes 

1 Thompson, op. cit., p. 193. 



RAPID DILATATION. 



289 



necessary to suspend the use of instruments for some days ; and to 
the treatment of no class of diseases is the motto "Festina lente" 
more applicable than to strictures. In addition to the arguments 
drawn from the pathology of stricture in favor of gentle and gra- 
dual dilatation ; it should be recollected that haste and violence 
must necessarily induce inflammation, which will surely be followed 
by additional plastic deposit and increased contraction. Yiolent 
measures of all kinds, though justifiable in rare instances for the 
relief of certain urgent symptoms, yet when applied for the cure 
of the stricture itself, are both unscientific and unworthy of the 
commendation which has been bestowed upon them. 

Eapid dilatation may be effected by means of conical sounds or 
bougies, the small extremity of which is introduced within the 
stricture and advanced by gentle but steadily continued pressure 
until the shaft, which is several sizes larger than the point, is fairly 
inserted ; the instrument may then be allowed to remain for several 
hours, and a larger one substituted for it. This method may some- 
times be adopted when time is of paramount importance, but its 
liability to do injury should constantly be borne in mind, and the 
utmost caution observed. 

Several instruments invented for rapid 
dilatation are constructed upon the com- 
mon principle of a series of tubes varying 
in diameter, which slide one upon another. 
In the instrument of Mr. Thomas Wakley, 
a No. 1 silver catheter is employed as a 
guide, which is first introduced into the 
bladder, and the tubes passed in succes- 
sion over it. When the desired degree 
of dilatation has been accomplished at 
any one session, a flexible catheter may 
be inserted in place of the largest silver 
tube which has been used, and, the con- 
ductor having been withdrawn, be retained 
until the next visit. From the strong tes- 
timony adduced by Mr. ~Y7akley in favor 
of his method, it would appear to be well 
worthy a trial in some cases. 

In the instrument invented by Dr. Buchanan, of Glasgow, the 
sliding tubes and a central conducting wire are united into a " com- 
19 



Fig. 18. 




290 



STRICTURE OF THE URETHRA, 



Fig. 19. 



pound catheter" (Fig. 18), which, is first introduced as far as the ob- 
struction, when the guide is pushed on through it together with as 
many of the tubes as will effect the desired degree of dilatation. It 
is stated by Mr. Thompson that this instrument has been claimed as 
a modern invention in London within the last few years, and such 
has also been the case in this neighborhood. 

M. Maisonneuve has invented an ingenious method of treatment 
which he calls " catheterisme a la suite." A very 
slender and flexible bougie, well adapted to pass the 
longest and most tortuous strictures, serves as a pio- 
neer; when once this is introduced, various instru- 
ments may be screwed to its external extremity and 
passed through the obstruction, following the bougie 
as a guide, the flexibility of the latter permitting it to 
be coiled up in the bladder as fast as it enters this 
cavity. If, for instance, it is desired to draw off the 
urine, a hollow bougie with an eye upon its side is 
screwed to the conductor and passed into the bladder, 
while larger bougies or a urethrotome may be attached 
for the purposes of dilatation or internal incision. 1 The 
guide is left in the urethra from one visit to another, 
so that there is no necessity for repeated introduction. 
Although this method is beautiful in theory, it can- 
not be said to have been fully tested in practice. It 
would appear probable that it may occasionally prove 
of value, especially in narrow strictures complicated 
with retention, when it is impossible to introduce any 
instrument but a filiform, flexible bougie, too small 
to draw off the urine ; and when otherwise it would 
be necessary to puncture the bladder. 



Expansion. — Attempts have been made to expand 
strictures : — 

1. By instruments made of some porous material 
which will dilate when moistened by the urethral 



A. Filiform bou- 
gie. B. Flexible 
catheter with an 



opening upon the secretions. Thus, bougies of "flexible ivory," or 

side, screwed to. , . , n . , , 

the former. ivory deprived ot its calcareous matter by lmmer- 



1 A catheter armed at the point with a hougie was employed for the relief of 
retention of urine by Dr. Physick, of Philadelphia, as early as 1796. Thompson's 
probe-pointed catheter is a modification of the same instrument. 



EUPTURE — CAUSTICS. 291 

sion in a weak acid, have been used for this purpose by the French ; 
bougies of slippery elm by Dr. Wm. A. McDowell, 1 formerly of 
Downesville, and Prof. Nathan Smith, of Baltimore ; and compressed 
sponge by Dr. Alquie, 2 of Montpelier, and Dr. Batchelder, 3 of this 
city. These attempts have not as yet, so far as I am aware, at- 
tained any satisfactory result, and in a trial of bougies of flexible 
ivory made by Kicord, the portion of the instrument which was 
introduced beyond the stricture dilated to such an extent that it 
was almost impossible to withdraw it, and the necessity of external 
incision became imminent. 

2. By sacs of oiled silk, gold-beater's skin, or other impervious 
material, which may be introduced through the stricture by means 
of a stylet, and afterwards dilated with air or fluid, as proposed by 
Ducamp, and Dr. James Arnott. 4 

3. By various instruments with expanding blades. 

The employment of all these methods has been chiefly confined 
to their inventors, and cannot be recommended as superior or even 
equal to other modes of dilatation. 

Eupture. — Still less can be said in favor of the forcible rupture 
of strictures, which is accomplished by instruments with expanding 
blades ; although Mr. Thompson, from the observation of six cases 
in the practice of Mr. Holt, states that this violent proceeding was 
productive of less unpleasant consequences than might have been 
expected on a priori grounds ; the ultimate effect upon the stric- 
ture is not stated. 

Caustics. — Caustics, at times extolled as the most efficient means 
of treating stricture, and at other times decried as useless and in 
the highest degree dangerous, have succeeded in maintaining a 
favorable position in the general estimation of the profession ; not, 
however, as an exclusive mode of practice, but as an adjunct to 
dilatation. It should be observed that these two methods are 
inseparable, even when not, as is usually the case, intentionally 
combined ; since the instruments employed in the application of 
caustics must necessarily distend the canal like bougies or sounds. 

1 Gross, op. cit., p. 778. 

2 Gazette des Hopitaux, 24 Juin, 1854, p. 300. 

3 New York Journal of Medicine, May, 1859. 

4 Stricture of the Urethra. London, 1819. 



292 STKICTUKE OF THE UKETHKA. 

This fact renders it somewhat difficult, in any case of successful 
treatment in which these remedies have been employed, to deter- 
mine what proportion of the credit is due to them and what to 
dilatation; but the general impression upon the minds of those 
who have given them a fair trial is sufficient to warrant the favora- 
ble opinion above expressed; which is founded not only upon 
the testimony of the warm advocates of this mode of treatment, 
Messrs. Whately and Wade, but also upon that of Mr. Henry 
Smith, Mr. Thompson, several personal friends in this city, in 
whose judgment I place the highest confidence, and my own ex- 
perience. 

It is necessary, however, to define with greater minuteness the 
position which caustics are believed to hold ; and this may be done 
in the following terms : — 

1. They are not to be used as escharotics for the purpose of 
destroying the plastic material which constitutes strictures ; hence 
of these agents the milder forms should be preferred, or the 
stronger caustics should be employed in small quantities only. 

2. They are especially adapted to cases of irritable stricture, in 
which they diminish sensibility and spasm, and permit of the 
freer use of dilatation ; 

3. To cases in which there is a strong disposition to hemorrhage, 
in which they control the vascularity of the part ; and 

4. To some cases of tough and fibrous contractions, in which 
they appear to assist dilatation by exciting absorption. 

The chief caustics employed in the treatment of stricture are 
nitrate of silver and caustic potash ; to the former of which my own 
experience has for the most part been confined. The mode of 
application is exceedingly simple. A depression is to be made in 
the extremity of a wax bougie, in which a small fragment of the 
solid nitrate is deposited, and the adjacent substance pressed around 
it, so as partially to overlap it and retain it in place. The instru- 
ment is then to be oiled, passed rapidly down to the anterior face 
of the stricture, or, if possible, within it, retained in position from 
one to two minutes, and then withdrawn. In the course of three or 
four days, a plug of coagulated mucus and epithelium may often 
be detected in the urine, the pain of micturition is lessened, and, on 
farther trial of dilatation — which should never be omitted — the 
sensibility of the canal is found to be much diminished. If the 
passage be of sufficient size, caustic may be applied to the interior 



CAUSTICS. 



293 



Fig. 20. 



*£- T' ; . . -—gj) 



of the stricture by means of Lallemand's porte-caustique, or, better 
still, with the instrument devised by Leroy D'Etiolles, which is free 
from an objection to which the former is liable, 
viz., that of being forcibly retained by the spas- 
modic action excited by the application. 

The nse of potassa fusa in the treatment of 
urethral stricture was first adopted and recom- 
mended by Mr. Whately, 1 who employed a very 
small quantity, not exceeding one-twelfth of a 
grain in weight, nor in size " a common pin's 
head," and only in case a bougie at least a size 
larger than the finest could be passed into the 
bladder ; that retention, if caused by the treat- 
ment, might be relieved by the passage of a 
catheter. A freer use of potassa fusa in imper- 
meable as well as permeable stricture has 
since been advocated by Mr. Wade, 2 whose 
views, founded upon an experience of thirty 
years and supported by the details of a large 
number of successful cases, entitle this agent to 
a more extended trial than has yet been given 
it; for, although occasionally mentioned with 
approval by various writers, and among others 
by our countryman, Dr. Gross, 3 it has not gene- 
rally met with much favor, and has been re- 
garded as too powerful and unsafe to be ex- 
perimented with. Mr. "Wade not only believes 
it as harmless as nitrate of silver, when used 
with proper caution, but that it possesses powers 
far superior ; that it is especially indicated in 
irritable and unyielding strictures, which of 
late years have been treated by incision ; and 
that it is calculated to supplant urethrotomy altogether, or to confine 
it to a very few exceptional cases. The following extracts from his 
work will still farther explain his views, and his mode of practice : — 

" The caustic potash may be advantageously applied to strictures 
for two purposes : one to allay irritation, the other to destroy the 




Leroy D'Etiolles' instru- 
ment for "lateral retro- 
grade cauterization." (Af- 
ter MORLAND.) 



1 An Improved Method of Treating Strictures in the Urethra. London, 1804. 

2 Stricture of the Urethra, 4th edition, London, I860, pp. 92-155. 

3 Op. cit., p. 788. 



294 STRICTURE OF THE URETHRA. 

thickened tissue which forms the obstruction. When used in the 
minute quantity employed by Mr. Whately, I believe its action to 
be simply that of allaying irritation, as, when mixed with lard and 
oil, combined with the mucus of the urethra, it can scarcely have 
any effect beyond a mild solution of caustic, which most probably 
causes a more healthy state of the lining membrane of the stric- 
ture. Before using the potash, a bougie should be passed down to 
the stricture, that its distance from the orifice of the urethra may 
be ascertained. A small piece of the caustic, about the size of a 
common pin's head to commence with, should be inserted into a 
hole made in the point of a soft bougie. The caustic should be 
broken just before it is required, and the inner or dark part se- 
lected, as the outer portion is usually less efficient, as it is com- 
monly converted into a whitish crust of carbonate of potash. Two 
notches should be made in the armed bougie, one marking the 
exact distance of the stricture ; the other, an inch beyond ; so that 
its progress, as it enters the obstruction, may be accurately ob- 
served. The bougie should be moulded with the finger round the 
potassa fusa, so that it may be securely fixed ; but to insure the 
action of the caustic, instead of being below the level of the hole, 
as recommended by Mr. Whately, its points should be fairly ex- 
posed to enable it to act upon the stricture. 

" The armed bougie should, of course, be well oiled before its 
introduction ; and if the points of the caustic be well covered with 
lard, there need be no fear of its acting before it reaches the stric- 
ture. The bougie should be gently pressed against the stricture 
for a minute or two if impermeable, and then withdrawn. "When 
the caustic is applied to permeable obstructions, the bougie should 
be passed three or four times over the whole surface of the stric- 
ture. To impermeable strictures, the caustic should be applied with 
greater caution than to such as are permeable ; for should reten- 
tion of urine occur, it will be more easily relieved in the latter 
than in the former. It usually happens that, after one or two ap- 
plications of the caustic, the bougie will be found to enter the 
obstruction. Before applying potassa fusa to impermeable stric- 
tures, every precaution should be taken to guard against irritation. 
If convenient, the application may be made at bedtime, taking care 
that the patient passes his urine just before; and should he have 
been subject to rigors or retention, it will be best to administer 
an opiate injection an hour previous to the operation. 



incisions. 295 

" It appears to me, that the principal superiority of this caustic 
to the nitrate of silver, consists in its more powerful solvent effect 
in removing hard strictures, and that with perfect safety and com- 
paratively with but little pain. Potassa fusa, when used for the 
destruction of a stricture, instead of causing a solid slough, appears 
to exert its salutary effects by a process of inflammatory softening 
and dissolution of the thickened tissue forming the obstruction. 

" The periods at which it will be most advisable to repeat the 
application of the potassa fusa must depend upon its effects, and 
the nature of the cases in which it is used. In many old chronic 
strictures, I have used the potash advantageously every second or 
third day ; and in some few instances, under peculiar circumstances, 
even oftener. When a strictuA has been so far removed by the 
application of potassa fusa as to admit the introduction of a middle- 
sized bougie, it will be best to discontinue the use of the caustic, 
unless there should be difficulty in its subsequent dilatation, when 
an occasional application of the remedy will often be found service- 
able." 

Incisions. — It is often asserted that when any instrument what- 
ever can be passed through a stricture, dilatation is all-sufficient, and 
that it is never necessary to resort to cutting instruments ; but 
although this statement is applicable to the majority of urethral 
contractions, it is not universally true ; for strictures are occasion- 
ally met with which are so unyielding that dilatation has little if 
any power over them ; or so irritable, that attempts at catheterism 
can only be made at long intervals ; or so resilient, that relapses 
constantly occur. Cases presenting these characteristics constitute 
one class of strictures, in which urethrotomy may often be employed 
with decided benefit; another class includes certain impassable 
strictures, and those complicated with false passages. 

The question is sometimes asked : " How can incisions effect any 
permanent good in cases of stricture ? None of the adventitious 
deposit is removed by urethrotomy : the lips of the wound must 
eventually unite, and the condition of the parts as before the 
operation be restored: why expect any more benefit than from 
simple incision of the bands of cicatricial tissue following burns, 
which are notoriously incurable by such a procedure?" The 
comparison is a good one, and may serve to show how far the power 
of urethrotomy extends. It is indeed true that unassisted by other 



296 STRICTURE OF THE URETHRA. 

measures ; it can ultimately add nothing to the calibre of the pas- 
sage, and is, therefore, alone incapable of effecting a permanent 
cure ; but, by giving free exit to the urine for the time being, it 
affords a period of rest ; the bladder recovers its tone ; congestion 
and spasm are relieved ; the vascularity of the part is decreased, 
and spontaneous absorption of a portion of the more recent deposit 
takes place. In this manner, great, though temporary, relief is 
obtained ; but the opportunity is afforded for accomplishing still 
more. Instrumental dilatation may now be practised under the 
most favorable circumstances ; much of the adventitious material 
of the stricture may be removed by thus exciting absorption, or, 
when this is too firmly organized to admit of resolution, the 
recent fibrinous deposit, which, as$n other parts of the body, takes 
place between the edges of incisions not united by first intention, 
may be mechanically dilated by the occasional passage of an in- 
strument ; the disease is thus kept in abeyance, and comparative 
comfort afforded. In the view here taken, urethrotomy is regarded 
as the pioneer of dilatation, the companionship of the latter being 
essential to give permanency to any good result ; and though much 
more than this has been claimed for this operation, such I believe 
to be its true office. 

Incisions may be internal, or from within; external, or from 
without ; in the former, but little more than the substance of the 
stricture itself is incised ; in the latter, the whole thickness of the 
tissues between the canal and the surface is divided. 

Internal Division. — Internal incisions should rarely be prac- 
tised except for strictures in front of or within the scrotum, or, in 
other words, in the straight portion of the urethra ; when division 
is required for strictures situated in the sub-pubic curve, external 
urethrotomy is generally to be preferred as safer and more satis- 
factory in its results. Non-dilatability, irritability, and resiliency, 
are the chief conditions which require internal incisions, and these 
are more frequently met with in strictures of the spongy than any 
other portion of the urethra. They are most marked in contrac- 
tions at the meatus, which can very rarely, if ever, be treated suc- 
cessfully by dilatation ; but they also affect, to a less degree, those 
which are situated within three or four inches of the external ori- 
fice, and to this portion of the urethra, in the opinion of most sur- 
geons of the present day, should internal urethrotomy be confined. 



INTERNAL DIVISION. 297 

Internal incisions should also be restricted to cases in which the 
whole thickness of the stricture can be completely divided by a 
cnt of moderate depth ; the danger of hemorrhage and of infiltra- 
tion of pus and urine from deep intra-urethral incisions is too great 
to admit of the internal division of thick masses of induration, 
which are more safely treated by external urethrotomy. The dis- 
tance between the point of the blade when fully projected, and the 
back of the instrument should rarely exceed four-tenths of an inch, 
which is the extent of the projection in Civiale's urethrotome, and 
in that of Mr. Thompson it is even less. 

A great variety of instruments have been proposed for internal 
incisions, some of which are intended to cut from before backwards 
by means of a projecting blade, which either has or has not a rod 
in front of it as a guide ; while others are designed to be passed 
through the stricture and then withdrawn, cutting from behind for- 
wards ; they are either straight or curved to correspond with the 
portion of the canal in which they are intended to be used. 

Urethrotomy from before backwards without a guide should 
never be performed except in the spongy portion of the urethra, 
and then only to prepare the way for the introduction of other 
instruments. In the deeper portions of the urethra it is highly 
dangerous, since the direction of the incision cannot be determined 
with accuracy, important parts may be wounded, or an outlet 
formed for the escape and extravasation of urine. Internal divi- 
sion from behind forwards should in all cases be preferred, both 
because it is safer, and because the edges of the cut are smoother 
and less jagged than when made in the opposite direction. 

Of the many urethrotomes which have been invented, Civiale's 
instrument, figured in the adjoining cut, is probably the best. It 
is designed to pass through the stricture, and divide it during its 
withdrawal, after the blade has been made to project. The termi- 
nal bulb, in which the blade is concealed, equals in diameter a 
No. 5 catheter, and hence the instrument cannot be employed when 
the passage is of less size ; for such cases, Mr. Thompson's urethro- 
tome, which is a modification of Civiale's, and the bulb of which 
does not exceed No. 2J or 3, is admirably adapted. 1 

1 The Value of Internal Incisions in the Treatment of Obstinate Strictures of the 
Urethra, London Lancet, Am. ed., Jan. I860. Many practical suggestions con- 
tained in this section have been derived from this valuable paper, to which the 
reader is referred. 



298 



STRICTURE OF THE URETHRA. 



The bulb at the extremity of the instrument will serve to deter- 
mine the extent of the stricture ; and the incision, implicating the 



Fig. 21. 



<?k 



Fig. 22. 



J 



Civiale's 
urethrotome 



(T^W- 



Fig. 22. 
Fig. 23. 



Fig. 23. 

Mr. Thompson's urethrotome. 

The same with the blade drawn out. 



floor of the canal, should commence from a quarter to 
half an inch beyond, and be prolonged to an equal 
distance in front of it, in order to insure its complete 
division. After the operation a full-sized catheter should 
be passed into the bladder (taking care to avoid en- 
tangling the point in the wound), and be retained for 
twenty-four hours, and dilatation should be practised at 
gradually increasing intervals for a period of several 
months. 

In case the stricture will not admit an instrument 
sufficiently large to cut from behind forwards, it may 
still be possible to introduce the slender rod which 
serves as a guide to the blade in many of the urethro- 
tomes which are designed to incise from before back- 
wards. Charriere's instrument is a valuable one, because 
it may be employed in either direction. 

In the rare cases of impassable stricture of the spongy 
portion of the urethra, internal urethrotomy may be 
performed by means of the "lancetted catheter," which 
consists of a canula and a blade projecting from its 
extremity. It is hardly necessary to observe that while 
using this instrument, the penis should not be bent upon 
its point, but that the portions in front of and behind 
the obstruction should preserve a straight line, in order to avoid 
wounding the sound urethral walls ; and the extremity of the 
urethrotome should, if possible, be insinuated within the orifice of 
the stricture before thrusting forward the blade. 



PEKINEAL SECTION. 



299 



Fig. 24. 



Fig. 25. 



B 



A 



Strictures at or near the meatus are peculiarly undilatable, and 
can rarely be successfully treated except by incision. When 
involving the meatus they may be 
divided by a curved sharp-pointed 
bistoury ; its point protected by 
wax during its introduction into the 
canal. (Fig. 26.) When situated a 
short distance from the external 
orifice, a probe-pointed tenotomy 
knife, or Civiale's concealed bis- 
toury (Fig. 27) may be vised. A 
plug of oiled lint may be inserted 
in place of a catheter, and be re- 
newed after each act of micturition. 
The strong tendency to reunion of 
the edges of the wound which 
always attends urethrotomy in this 
part of the urethra, should be care- 
fully guarded against. 



PEKINEAL SECTION. 

The external division of stricture 
by an incision through the peri- 
neum had, for several centuries, been 
known as the "boutonniere opera- 
tion," or "perineal section," when, 
in 1849, Mr. James Syme, of Edin- 
burgh, published a work 1 in which 
he advocated its employment ex- 
clusively in permeable strictures, 
through which a staff could be 
passed to serve as a guide, and 
recommended its adoption in a large 
— and, in the opinion of the mass of 
the profession, an unjustifiable — 
proportion of urethral contractions. Since this time, perineal 
section upon a guide has been called "Syme's operation," or 



Charriere's urethro- 
tome, attached to a con- 
ducting bougie, useful 
•when the passage is much 
contracted, and which 
may he detached and the 
point B screwed on. 



Lancett ed 
catheter. (Af- 
ter Gross.) 



1 Stricture of the Urethra, Edin., 1849, p. 58. 



300 



STRICTURE OF THE URETHRA. 



11 perineal division/' while the names "boutonniere operation," 
"perineal section/' and "external urethrotomy," have been restricted 
to the same operation without a guide. While acknowledging the 

Fig. 26. 




Fig. 27. 

(After Phillips.) 

credit due to Mr. Syme for having carefully studied the various 
steps of this operation, and for the introduction of certain improve- 
ments in the manner of its performance, it is yet difficult to explain 
on what grounds this innovation in name has been made; for, 
should Civiale's statement be called in question, that a staff was 
employed by Tolet two centuries ago, it is certain that one was 
frequently used by many operators, both abroad and in this 
country, long before the appearance of Mr. Syme's essay; and, 
waiving the question of priority, the difference in the two methods 
is not sufficient to warrant the proposed distinction, which will be 
ignored in the present volume as it has been by many other 
writers. 1 

1 With reference to the history of external urethrotomy, see an interesting article 
entitled : " Note historique et critique sur l'urethrotoraie externe ou section des 
retrecissements de dehors en dedans, avant le 18 e siecle," by Dr. Verneuil, in the 
Archives Generales de Med., Sept. 1857. 



PERINEAL SECTION. 301 

Perineal section was adopted in America in the early part of 
the present century, and, for the last forty or fifty years, has been 
the favorite mode of treatment for advanced cases of stricture 
which could not be benefited by other means. In the registry of 
cases in the New York Hospital, which was at first so meagrely 
kept, that vol. i. extends from 1808 to 1831, I find a record of its 
performance, Aug. 30, 1811, upon James Waram, for the relief of 
a stricture "nearly three inches in length;" the name of the ope- 
rator not given, but probably Dr. 1ST. Seaman. Nothing is said 
which would lead to the supposition that the operation was re- 
garded as unusual or novel at that time, and according to the 
testimony of several of our older surgeons, among whom I would 
mention the venerable Dr. Alexander H. Stevens, it was frequently 
adopted prior to 1820. 

Dr. H. G. Jameson, Surgeon to the Baltimore Hospital, published 
a valuable paper on perineal section in the American Medical Re- 
corder, for 1824. 1 His first successful operation was performed 
Dec. 2, 1820, and its conception appears to have been original with 
him, for he speaks of it as " an operation which I had long pro- 
jected, but which I felt unwilling to hazard without some prece- 
dent." At the close of his paper he gives the following summary : 
"I have reported ten cases in which I opened the urethra, and 
thereby cured the most deplorable strictures, and one case attended 
with a relapse, in which mortification took place, and yet the pa- 
tient recovered ; making of course eleven successful cases. Among 
these cases there have been four of mortification of the scrotum, 
one accompanied with fistula in the perineum, two in which the 
urethra was opened both through the penis and the perineum. 
And it is further to be understood, that no unfortunate cases have 
been concealed, and that from the time I commenced my operations 
upon the urethra, I have not lost a single patient." Dr. Jameson 
expresses the opinion that, in all cases of retention of urine, peri- 
neal section should be substituted for puncture of the bladder. 
Dr. Edward Hartshorne, writing in 1855, speaks of perineal section 
as an " operation which has long been a familiar one in Philadel- 
phia." 2 

But in no place in America has there been a greater, nor, it is 

' Vol. vii. p. 251. 

2 Review of Thompson on Stricture, Am. Jonrn. of the Med. Sci., July, 1S55. 



302 STRICTURE OF THE URETHRA. 

believed, so great an opportunity for studying the performance 
and the results of perineal section as in New York, where this 
operation, for the last forty or fifty years, may be said to have been 
identified with the City Hospital and the surgeons connected with 
this institution. This fact is one of common notoriety, and is at- 
tested by the elder men of the profession in this neighborhood ; 
though it is to be regretted that this field for observation has not 
been made more productive to science by the publication of the 
valuable material which might here have been gathered by men 
so well qualified for the task. An honorable exception to this 
general neglect is to be found in two papers by Dr. Lente, Surgeon 
to the West Point Foundry, formerly House Surgeon of the New 
York Hospital, the first of which, entitled " Surgical Statistics of 
the New York Hospital," was published in the Transactions of the 
American Medical Association, vol. iv. 1851 ; and the second, on 
" Perineal Section for Stricture of the Urethra," in the New York 
Journal of Medicine, March, 1855. Dr. Lente gives a tabular state- 
ment of twenty-seven cases of perineal section, most of which 
occurred during his three years' residence as house surgeon at the 
hospital, and of which number three died, six were relieved, and 
eighteen were cured. " In most, if not all of the cases, the opera- 
tion was regarded as the only means of effecting a cure, all other 
means having failed ; and, in many instances, it was necessary, not 
only for the purpose of rendering the patient's life more comfort- 
able, but for saving it." 

The principles which should determine the surgeon in deciding 
upon perineal section, may be stated as follows : — 

1. It should not be regarded as applicable to any considerable 
proportion of the whole number of strictures, but be reserved for 
exceptional cases, in which milder means have failed. 

2. It should not be employed in a low state of the vital powers, 
nor when extensive disease of the kidneys is present, since, under 
these circumstances, the danger of a fatal result is materially in- 
creased. 

3. It is advisable in impassable, unyielding, highly irritable or 
resilient strictures, which have proved incurable under a thorough 
and persevering trial of dilatation. The presence of false passages 
is an additional inducement for its performance, since the abnormal 
channel may be cured at the same time that the stricture is re- 
lieved. 



PERINEAL SECTION". 303 

4. It is justifiable in some cases of retention of urine dependent 
upon stricture, although in most instances puncture of the bladder 
is to be preferred. 

It is highly desirable that the patient should be prepared for the 
operation by a period of rest, during which he should be confined 
to the house, and, for the most part, to the horizontal posture, his 
secretions be regulated, and his system placed in as favorable a 
condition as possible. The perineum should be shaved, and the 
rectum evacuated by an enema. The stricture may present three 
degrees of contraction ; it may be entirely impervious to any in- 
strument ; it may admit a fine elastic bougie ; it may be possible 
to introduce a grooved sound. In the first case, a catheter of full 
size is required for insertion in the urethra; in the second, the 
largest possible bougie should be passed into the bladder and a 
metallic tube, open at the extremity, introduced upon it as a guide 
as far as the obstruction ; in the third, the staff employed by Mr. 
Syme, and which will presently be described, is very serviceable, 
although a similar combination of a sound and catheter, as in the 
last case, will answer every purpose. 

The patient, having been brought under the influence of an anaes- 
thetic, is placed upon the edge of a table, facing a good light, in 
the position for lithotomy, with the hands bound to the feet by 
bandages, and an assistant supporting each knee. The assistant 
on his left takes charge of the instrument introduced into the ure- 
thra, and elevates the scrotum out of the way of the operator ; the 
metallic sound or catheter is to be pressed firmly against the ob- 
struction in such a manner as to render its extremity somewhat 
prominent. The surgeon, sitting upon a low stool, makes an inci- 
sion, an inch and a half or two inches in length, exactly in the 
median line of the perineum, and dividing the tissues by successive 
strokes of the scalpel, opens the urethra upon the extremity of the 
instrument in front of the obstruction ; and here it is to be observed 
that it is better to extend the incision upwards a short distance 
above the extreme point of the catheter, in order to insure the com- 
plete division of the stricture in this direction. 

The urethra having been opened, the facility of completing the 
operation will depend very much upon whether a guide has been, 
or can be, passed through the contraction. When a bougie or star? 
has been introduced into the bladder at the commencement, the 
division of the stricture upon it is comparatively easy. If this was 



304 STRICTURE OF THE URETHRA. 

found impossible; the next undertaking is to endeavor to pass an 
instrument through the perineal opening. For this purpose, the 
edges of the incision should be held apart by the fingers of assist- 
ants, or by means of hooks, or, as proposed by Mr. Avery, a liga- 
ture may be passed through the urethral mucous membrane on 
either side, in order to afford a clearer field of view, and indicate 
the position of the channel ; and the blood should be removed by 
constant sponging. The most desirable instrument to insert is a 
grooved director ; if this cannot be passed, a fine, flexible bougie, 
or even a bristle, may be tried. Considerable time, patience, and 
perseverance are required in this part of the operation, which often 
occupies from fifteen to thirty minutes, but in most cases, one of the 
above instruments may eventually be passed. Dr. Grurdon Buck, 
whose experience in perineal section has been extensive, informs 
me that he has never met with a case of failure, but I have known 
other surgeons to be less fortunate. If success be attained, the 
stricture should be divided from below upwards, 1 taking care to in- 
clude its whole extent, but avoiding making the incision so far back- 
wards as unnecessarily to wound the deep perineal fascia, whereby 
the danger of extravasation of urine would be increased. Mr. 
Syme states positively that he has " never found it necessary to cut 
farther back than the bulbous portion, for the conveyance of a full- 
sized instrument into the bladder," and that he has never met with 
a contraction situated posteriorly to this point ; but that strictures 
do exist in the membranous portion, there can be no question, 
although Mr. Syme's statement is probably nearer the truth than 
has sometimes been admitted, since the universal tendency has been 
to assign a seat posterior to the true one, and the oblique direction 
of the perineal fascia which shortens the inferior aspect of the 
membranous region is liable to lead into this error. While, there- 
fore, we cannot always expect to avoid opening the deep perineal 
fascia, it should be guarded against, if possible, and need not fre- 
quently occur. 

In some cases, as already intimated, it is found impossible to 
introduce any guide whatever through the obstruction. It then 
becomes necessary to search for the urethra posterior to the stric- 
ture, by carefully dividing the tissues in the median line; if a 

• Lest, if made in the opposite direction, the knife, after severing the stricture 
and ceasing to meet with resistance from the mass of induration, unnecessarily 
wound the deeper tissues. 



PERINEAL SECTION. 305 

fluctuating point be felt, it is probably the dilated urethra, and 
should be opened. It is evident that under these circumstances it 
must often be impossible to trace the contracted and thread-like 
passage through the intervening mass of induration ; and much 
time need not be expended in the attempt, if it be not readily 
found; since the new channel opened by the knife has, in nu- 
merous instances, supplied the place of the original canal in a very 
satisfactory manner. 

A free passage having been opened into the bladder, a full-sized 
catheter should be introduced from the meatus and retained. 
When a bougie and sliding tube were passed at the commence- 
ment of the operation, the latter is readily pushed on to the blad- 
der upon the former as a guide. Otherwise some difficulty may 
be experienced in introducing the catheter, the point of which is 
liable to protrude through the perineal opening, and should be 
guided in the proper direction upon a broad director first inserted 
through the incision. After the introduction of the catheter, it 
should be ascertained if it be freely movable in the canal ; if it is 
felt to be "held," some fibres of the stricture probably remain 
uncut, and should at once be incised ; since their complete division 
is essential to the success of the operation. The catheter is retained 
by means of a bandage around the waist, to which two perineal 
straps are attached before and behind, and the rings of the instru- 
ment are connected with the latter by threads. The catheter 
should not be inserted so far that its point will press against the 
mucous . membrane of the bladder. It is better that its external 
extremity should not be closed, but be connected with a urinal by 
means of an India-rubber tube, in order that the urine may find 
free exit and less escape through the wound. The patient should 
now be put to bed with the thighs elevated and the bedclothes 
supported by a cradle. Pain may be relieved by suppositories of 
opium. Subsequent hemorrhage sometimes occurs which it is 
difficult to arrest by ligature, since the thread does not retain a 
firm hold upon the gristly tissue of the stricture ; it may, however, 
be effectually controlled by inserting a piece of compressed sponge 
between . the edges of the wound, or firmly plugging it with lint, 
and bandaging the thighs together. 

The catheter may be ajlowed to remain two or three days, but 
never more than four, unless in rare instances, when an elastic 
20 



306 STRICTURE OF THE URETHRA. 

should be substituted for the metallic instrument, or the former 
may be employed from the first. This rule is an important one. 
The danger of prolonged retention lies in the liability to produce 
ulceration of the mucous membrane and subjacent tissues in con- 
sequence of pressure of the instrument. This most frequently 
occurs at two points : one, that portion of the vesical walls which 
comes in contact with the extremity of the catheter ; the other, 
the lower surface of the urethra just in advance of the scrotum, at 
the commencement of the sub-pubic curve, where the penis is 
upheld by the suspensory ligament, and where any straight in- 
strument, like the shaft of a catheter, necessarily presses upon the 
inferior wall of the canal. A number of cases illustrating these ill 
effects have been exhibited at various medical associations of this 
city within a few years. In one instance death occurred after the 
catheter had been retained a fortnight, and at the post-mortem 
examination there was found a small but deep ulceration of the 
bladder, and another, quite extensive, of the inferior wall of the 
urethra in front of the scrotum, which was only separated from 
the surface by the integument. A few years since a man, who had 
been operated upon by perineal section in California, and in whom 
a silver catheter had been retained for three weeks, applied to a 
surgeon of this city for the relief of urinary fistula at the angle 
between the penis and scrotum, consequent upon this prolonged 
retention. The injurious effects of such ulceration must be more 
than local ; in subjects so debilitated as patients with stricture often 
are, they must contribute to the fatal result which sometimes 
ensues. 

The idea sometimes advanced that perineal section is alone suffi- 
cient for the cure of stricture, is, with a few very rare exceptions, 
unquestionably erroneous. Unless catheterism be subsequently 
practised as after other modes of treatment, a relapse is almost sure 
to occur. I have been impressed with this fact in conversing upon 
the operation with different surgeons ; having found that those who 
did not resort to the subsequent passage of instruments were inva- 
riably disappointed, while those who did, were as constantly pleased 
with the results. One gentleman, who has performed it in nine 
cases, but who has never followed up the treatment with repeated 
catheterism, tells me that in every instance the disease has returned 
with its original severity. In this city this principle is well un- 
derstood ; dilatation is usually commenced the day following the 



PERINEAL SECTION. 



307 



withdrawal of the catheter, and is repeated every twenty-four 
hours, the instrument being left in about half an 
hour on each occasion. By the time the peri- 
neal wound is healed the patient may be taught 
to pass a catheter upon himself and be dis- 
missed, impressed with the importance of con- 
tinuing it for a long period. When an entirely 
new passage for the urine has been opened, or 
when the stricture was extensive and firm, direc- 
tions should be given to pass an instrument 
daily, either just before going to bed or early in 
the morning, and leave it in the urethra half 
an hour; this is to be continued for at least 
six months, after which period catheterism is to 
be repeated at gradually increasing intervals 
for several years. Unless these directions are 
faithfully carried out no one need expect the 
slightest permanent benefit from perineal section. 

When perineal section is followed by a fatal 
termination, it is in most cases due to pygemia ; 
sometimes to urethral fever, attended or not 
with suppression of urine ; and at other times 
to hospital gangrene, erysipelas, or urinary in- 
filtration. A large proportion of the deaths 
have occurred in hospitals ; in private practice, 
perineal section is found to be a comparatively 
safe operation, especially if confined, as it in- 
variably should be, to patients endowed with 
that amount of vigor which is always requisite 
when the knife is to be used. 

In performing "external division," Mr. Syme 
employs a staff with a slender grooved extremity, 
which equals in diameter No. 1 or 2 of the 
catheter scale, and is intended to pass through 
the stricture ; while the main shaft, corresponding in size to No. 
8, unites abruptly with the former, and is arrested at the anterior 
edge of the stricture (Fig. 28). Mr. Thompson uses a similar instru- 
ment, but "constructed with a hollow throughout, by which the 
urine issuing when it arrives at the bladder, the operator knows 
that the slender point is in its proper place, a satisfactory assurance 




308 



STRICTURE OF THE URETHRA. 



when false passages exist, and render the right route rather diffi- 
cult of access." 

Mr. Syme gives the following directions respecting the mode 
of performing the operation: "The patient should be brought to 
the edge of his bed, and have his limbs supported by two assis- 
tants, one of them standing on each side. A grooved director, 
slightly curved, and small enough to pass readily through the 
stricture, is next introduced and confided to one of the assistants. 

Fig. 29. 




(After Thompson.) 



The surgeon, sitting or kneeling on one knee, now makes an inci- 
sion in the middle line of the perineum or penis, wherever the 
stricture is seated. It should be about an inch or an inch and a 
half in length, and extend through the integuments, together with 
the subjacent textures adjacent to the urethra. The operator then 
taking the handle of the director in his left, and the knife, which 
should be a small straight bistoury, in his right hand, feels, with 
his forefinger guarding the blade, for the director, and pushes the 
point into the groove behind, or on the bladder side of the stric- 
ture (Fig. 29), runs the knife forwards, so as to divide the whole of 



PERINEAL SECTION. 309 

the thickened texture at the contracted part of the canal, and with - 
draws the director. Finally a No. 7 or 8 silver catheter is intro- 
duced into the bladder, and retained by a suitable arrangement of 
tapes, with a ping to prevent trouble from discharge of urine. 1 
The process having been thus completed, the patient has merely 
to remain quietly in bed for forty-eight hours, when the catheter 
should be withdrawn and all restraint removed." 

In a clinical lecture, published in the London Lancet (Am. ed.), 
Nov. 1848, Mr. Syme recommends that a catheter through the ure- 
thra should be entirely dispensed with after perineal section, and 
that a short tube through the perineal incision should be substituted 
for it, the better to protect the edges of the wound from contact 
with the urine, which appears to be the exciting cause of the rigors, 
vomiting, rapid pulse, and delirium, which, known as "urethral 
fever," sometimes follow this operation. The short catheter recom- 
mended by Mr. Syme, "is about nine inches in length, slightly 
curved in opposite directions at its extremities, and having a 
couple of rings just behind the anterior bend for securing it in its 
place. In addition to the great advantage of affording perfect secu- 
rity, this catheter is much less irksome to the patient than the one 
hitherto in use, and cannot, like it, produce any bad effect by press- 
ing upon the coats of a contracted bladder." 

Mr. Syme boldly takes the ground that this operation, even 
when not absolutely required by the obstinacy of the case, " is pre- 
ferable to dilatation, as affording relief more speedily, permanently, 
and safely." Holding these views, it is not to be wondered at that 
his operations amount to between one and two hundred, but the 
freedom with which he resorts to perineal section is justly censured 
by the almost unanimous voice of the profession. Eecently, Mr. 
Syme has declined to give the exact number of his cases, or the 
results. He had previously stated that not one of his first seventy 
operations was fatal, but since then several deaths have been known 
to occur in his practice. It may readily be conceded that his suc- 
cess, so far as regards mortality, has been unusually great, when it 
is recollected that he performs the operation in cases of a mild 
character, which must for the most part be free from renal disease 
and general depression of the system ; but results thus obtained 

1 Mr. Thompson, expressing, as it would appear, Mr. Syme's latest views, says 
that the end of the inlying catheter should not be closed. 



310 STRICTURE OF THE URETHRA. 

cannot be taken as an indication of the safety of perineal section in 
advanced cases of stricture. Mr. Thompson gives a list of 219 cases 
by thirty operators, among which there were fifteen deaths ; of these 
he would exclude two which were not chargeable to the operation, 
leaving fourteen, or about six per cent. This amount of mortality 
is sufficient to forbid perineal section whenever milder, though 
perhaps slower, measures can be successfully employed. 

Consequences of Operations upon Stricture. — Either of the 
modes of treatment now described may be followed by rigors and 
other unpleasant symptoms, which in most cases subside without 
evil result, but which sometimes become serious, and terminate in 
speedy death. The exciting cause may be simple over- distension 
of the urethra by a larger bougie than has before been used ; abra- 
sion or laceration of its walls by rough handling of the instrument ; 
the application of caustic ; or the employment of the knife in in- 
ternal or external incisions. The patient is suddenly seized with 
a chill, vomiting, acceleration of the pulse, and in severe cases 
with great prostration and delirium. These symptoms are most 
likely to ensue upon the first act of micturition succeeding the 
introduction of a sound, or the withdrawal of the catheter after 
urethrotomy ; in other words, they follow, and appear to depend 
upon, contact of the urine with an abraded surface, through which 
urea or pus finds entrance into the general circulation ; in other 
instances they are apparently due to the shock impressed upon the 
nervous system alone. This combination of symptoms, which is 
known as " urethral fever," is but one form of surgical fever, in the 
etiology of which the absorption of septic matter from the neigh- 
borhood of wounds plays so important a part, and which has been 
so ably and thoroughly described by Erofessor Simpson, of Edin- 
burgh. 1 

In most cases, urethral fever terminates in resolution, either with 
or without treatment, in the course of a few hours ; but, especially 
in persons affected with renal disease, and in some instances with- 
out apparent cause, a typhoid condition with delirium sets in, 
abscesses may form in different parts of the body, and speedy death 
ensues. Complete suppression of the urine is an occasional symp- 
tom, and is to be regarded as of very serious import. Mr. Thomp- 

1 Med. Times and Gaz., April 23, 1859. 



CONSEQUENCES OF OPERATIONS UPON STRICTURE. 311 

son relates a " case of old standing and narrow stricture, in which 
death was thus caused within fifty-four hours of the passing of an 
instrument, the same that had been habitually employed on at least 
a hundred occasions before, no damage whatever having been in- 
flicted by it upon the urethra, as verified by several careful observ- 
ers on close post-mortem examination of the parts. Eigors and 
vomiting commenced about an hour after the catheterism, and not 
another ounce of urine was secreted from that until death. In this 
case the kidneys were found congested to an extraordinary degree, 
and their substance was so soft and friable as to give way under 
gentle pressure." 

In a case of perineal section reported by Mr, Syme, "the patient 
suffered nothing from the operation ; had the catheter taken out on 
the second day; was quite well on the third, and on the fourth was 
lying dressed upon the sofa in the best of spirits. In the afternoon 
of that day, during the act of micturition, he felt an acute pain in 
the perineum, and in walking from one room to another, fell on the 
passage so as to graze his forehead and the outer side of his knee ; 
at the same time he had a violent rigor, followed by quick pulse 
and great pain in the injured parts. As the urine passed freely 
and entirely by the urethra, I expected that these symptoms would 
soon subside, but they continued and went on to suppuration of 
the knee, with destruction of the eyeball, and terminated fatally at 
the end of several weeks. I felt quite unable to account for this 
case until the following one gave me additional light on the sub- 
ject: The patient suffered nothing from the operation, which was 
of the simplest kind, and as he did not complain at all of the 
catheter, was allowed to retain it three days. When it was then 
removed, he. expressed perfect comfort, and afterwards wrote to his 
friends at home the most satisfactory account of his progress. At 
three o'clock of the afternoon he passed urine, and felt some pain 
in doing so, which was attended by a slight discharge of blood. 
Immediately afterwards he had a violent rigor, followed by delirium 
and insensibility. There was no pulse, no secretion of urine, and 
he died the next day. On examination there was not the slightest 
trace of urinary extravasation, or any other sign of local mischief; 
but the kidneys were gorged with blood to an extreme degree ; and 
it was plain that death had resulted from a sudden shock to the 
nervous system." 1 As already stated, so fatal a result of operations 

1 London Lancet, Am. ed., Nov. 1858. 



312 STRICTURE OF THE URETHRA. 

upon the urethra is not frequently met with, but the possibility of 
its occurrence should always be borne in mind, and lead to the 
observance of due caution. 

In order to conduct the treatment of stricture with safety, the 
general system should be in as favorable a condition as possible ; 
the digestive organs in good order ; and the patient should avoid 
excess both in diet and exercise. It is important also to abstain 
from any operative procedure during the persistence of raw and 
damp weather, or when the patient is fatigued or mentally de- 
pressed. Let the bladder be evacuated immediately before the 
introduction of the catheter, or the use of caustic or the urethro- 
tome, that the succeeding act of micturition may be deferred for 
several hours, when the abraded surface of the stricture shall be 
in a measure protected by an effusion of lymph. If rigors occur, 
they should be met by the external application of heat and rube- 
facients, as bottles of hot water to the extremities, sinapisms to the 
spine and abdomen, hot blankets, etc. ; and internally by stimulants 
and opiates. A full dose of the latter should be administered at 
the outset, and a smaller quantity be repeated every few hours, so 
as to maintain a steady narcotic action and lull the irritability of 
the nervous system. The reaction which generally follows should 
not be treated by active depletion ; a tendency to general depres- 
sion soon supervenes, in which the vital powers must be supported 
by stimulants and nourishment until nature shall have eliminated 
the toxical materials which have found entrance into the system. 

TREATMENT OF RETENTION OF URINE. 

Retention of urine, as already stated in this chapter (p. 264), 
chiefly occurs either during the acute stage of gonorrhoea, when it 
is due to inflammation and spasm ; or at some period of organic 
stricture, when, in addition to the causes just mentioned, perma- 
nent contraction of the canal plays a more or less important part 
in its production. It is less frequent in the former case than in the 
latter, and presents less difficulty in the way of treatment. Reme- 
dial measures must vary somewhat with the condition of the 
patient, and be determined by the judgment of the surgeon. 

When dealing with a subject of full habit, or if there be much 
heat and swelling of the genital organs, or general febrile excite- 
ment of a marked character, it is best to commence with the appli- 



TREATMENT OF RETENTION OF URINE. 313 

cation of cups or leeches to the perineum. The former are pre- 
ferable, as they abstract blood more rapidly, and abont ten ounces 
of this fluid may be regarded as an average quantity to be drawn. 
If the latter be employed, they should not be less in number than 
ten or twelve. Either with or without this preliminary local deple- 
tion according to the circumstances of the case, the patient should 
be immersed in a hot bath, the temperature of which should be 
raised to the neighborhood of 102° F., which will probably require 
the addition of hot water after his entrance, since the bath cannot 
at first be borne at so great a degree of heat, and is moreover 
cooled by contact with the body. It is even desirable that a state 
of syncope should be induced, which will greatly favor the reduc- 
tion of spasmodic action. In most cases, the patient will pass his 
urine during immersion ; otherwise, before his removal and while 
still in the water, a medium sized catheter, as, for instance, No. 5, 
should be well warmed and oiled, and an attempt be made to 
introduce it; following the rules already laid down, adhering 
closely to the upper surface of the urethra, stopping for a moment 
whenever an obstruction is met with, and endeavoring to overcome 
it by gentle but continuous pressure : by observing these directions, 
and avoiding the employment of force, no fear need be entertained 
of doing injury to the inflamed and sensitive mucous membrane. 
In the rare instances in which these measures do not succeed, the 
patient should be put to bed, maintained in a state of perfect qui- 
etude and rest, and other means of an antiphlogistic and antispas- 
modic character adopted. A brisk purgative, as croton oil or a full 
dose of calomel and jalap, may be administered at once, and be 
assisted by the following mixture repeated every two or three 
hours, in order to keep the stomach nauseated and the bowels 
free : — 

R. Antimonii et potassse tart. gr. iv. 

Magnesia? sulphatis §ij. 

Tincturse opii gtt. xl. 

Aquse camphorse §viij. 
M. 
Dose. — A tablespoonful. 

Excessive catharsis should, however, be avoided : two or three 
free evacuations are sufficient ; and any tendency to too great action 
may be controlled by opiate enemata. Indeed, it is always desirable 
and not inconsistent with the measures just advised, to allay irri- 



314 STRICTURE OF THE URETHRA. 

tability and spasm by keeping the system under the influence of 
opium, and this can be accomplished in no better way than by 
rectal injections or suppositories containing laudanum or morphine. 
If the urine fail to pass in the course of twenty-four hours, an 
attempt at catheterism may be repeated while the patient is again 
immersed in a hot bath, or, better still, after the administration of 
an anaesthetic. It can never be necessary to resort to puncture of 
the bladder when retention of urine is dependent upon inflamma- 
tory stricture. After relief has been obtained, the catheter should 
be withdrawn, to be reintroduced if found requisite, and a condition 
of rest should be maintained for several days after the urine has 
regained its normal freedom. 

But retention of urine is most frequently observed as a com- 
plication of organic stricture, when its symptoms are generally 
more alarming and with greater difficulty relieved. The remedial 
measures required vary somewhat from those above given. Unless 
the case has already been subjected to instrumental interference, 
an immediate attempt should be made to introduce a catheter, 
which will be greatly facilitated by placing the patient under the 
influence of ether. First, however, if he have not previously been 
seen by the surgeon, the necessary questions should be asked to 
learn the history of his case ; the degree of contraction of his stric- 
ture; what instruments it will admit, or, in default of this, the size 
of his stream of urine, the duration of the retention, etc. etc. The 
effect of anaesthetics in relaxing the sphincter of the bladder is fre- 
quently observed when these agents are employed for other pur- 
poses, as the stains upon the lounge and carpet of a surgeon's office 
can testify. In retention of urine, the contraction of the muscles in 
the neighborhood of the bladder and urethra is excessive, being 
not only stimulated by the will, but rendered spasmodic and in- 
voluntary by irritation of the afferent nerves ; and thus arises one 
chief obstacle to the natural or artificial evacuation of the bladder, 
which can be removed far more speedily and effectually by the 
modern application of ether or chloroform, than by hot baths and 
opium, which were formerly solely relied on for the purpose. 

The patient having been rendered insensible and his muscles 
thoroughly relaxed, the situation of the stricture should be ascer- 
tained by the introduction of a full-sized instrument; after which 
gentle and persevering attempts should be made to pass the ob- 
struction with a small metallic or gum-elastic catheter. If not sue- 



TREATMENT OF RETENTION OF URINE. 



315 



cessful with this, a small bougie of 
gum, whalebone, or catgut may be 
insinuated within the orifice, and 
allowed to remain a few moments, 
when its withdrawal will often be 
followed by a fine stream of urine ; 
and by repeating the process, if 
necessary, the entire contents of the 
bladder may be evacuated. The 
same result may sometimes be ob- 



tained, though with less certainty, 
against the anterior 
stricture. Again, in 



by pressure 
face of the 
strictures so contracted that noth- 
ing but a filiform instrument will 
pass, or at least none large enough 
to admit of being hollow, the inge- 
nious contrivance of " catheterisme 
a la suite," as employed by MM. 
Maisonneuve and Phillips, may be 
adopted, if the proper instruments 
be at hand (see p. 290). 1 Mr. 
Thompson 2 has also invented a 
catheter "combining tubular con- 
struction with minute size," the 
extremity of which Can be made as 
small as the finest metal probe, and 
is solid up to about two and a half 
inches from the point, where the 
eye is situated; while the hollow 
shaft above gradually enlarges, first 
to No. 1, and then nearly to No. 2. 
A steel rod, capable of being screw- 
ed in during the introduction of the 
instrument, gives it solidity, and 
prevents the eye from becoming ob- 
structed with mucus or blood. 




Thompson's "probe-pointed catheter 



1 An instance of the successful application of this method for the relief of reten- 
tion, in the hands of Dr. Phillips, is recorded in Championniere's Journal of Prac- 
tical Medicine and Surgery, for Dec. 1859, p. 552. 2 Op. cit., p. 181. 



316 STKICTURE OF THE URETHRA. 

After the successful introduction of a catheter in cases of reten- 
tion dependent upon organic stricture, the instrument should be 
retained in place to obviate subsequent trouble. 

Attempts at catheterism may be prolonged to such an extent as 
to irritate and abrade the canal, even if no violence be used. This 
should be avoided ; and if success be not attained after a reasonable 
length of time, other measures should be resorted to. Many cases 
also come under the care of the surgeon, in which instruments 
have already been used to excess by unskilful hands and in no 
gentle manner, and in which the urethral walls have been lacerated 
or false passages opened. Under these circumstances it is best to 
defer any further instrumental interference for a time. The patient 
should be immersed in a hot bath to the verge of syncope and 
removed to bed, and flannels wrung out of laudanum and hot water 
applied to the genital organs and hypogastrium ; but the most 
reliable remedy at this time is opium, with respect to which Sir 
Benjamin Brodie says : " From half a drachm to a drachm of lau- 
danum may be given as a clyster in two or three ounces of thin 
starch. If this should not succeed, give opium by the mouth, and 
repeat the dose, if necessary, every hour until the patient can make 
water. According to my experience, the cases in which the stricture 
does not become relaxed under the use of opium, if administered freely, 
are very rare. The first effect of the opium is to diminish the 
distress which the patient experiences from the distension of the 
bladder. Then the impulse to make water becomes less urgent ; 
the paroxysms of straining are less severe and less frequent ; and 
after the patient has been in this state of comparative ease for a 
short time, he begins to void his urine, at first in small,' but after- 
wards in larger quantities." The testimony of this distinguished 
surgeon is confirmed by the experience of nearly every practi- 
tioner ; at the same time it is proper to remark that the effect of 
this drug should be carefully watched, and that it should not be 
pushed to excess. 

The muriated tincture of iron is also a valuable remedy in cases 
of retention, and is much employed, especially at the New York 
Hospital, where it is given in doses of fifteen to twenty drops every 
half hour. Some doubt has been thrown upon the action of this 
agent, from the fact that it is commonly administered in conjunction 
with opium, to which the credit in successful cases has been ascribed. 
I have used it alone in several instances with very favorable results, 



TREATMENT OF RETENTION OF URINE. 317 

and am disposed to assign it a position second only to opium in the 
treatment of retention. 

In every case of this affection, the perineum should be subjected 
to a careful examination, since the obstruction may be caused by an 
abscess or urinary infiltration, the evacuation of which will at once 
afford relief. When such collections form posterior to the triangular 
ligament, the external symptoms are often very obscure. If any 
swelling or doughy hardness can be detected, a free incision should 
at once be made in the median line with a bistoury. This can do 
no harm, and is likely to be of essential service. Any collection of 
feces in the rectum should be avoided, and the bowels, if not open, 
must be moved by an enema or cathartic. In subjects of a full 
habit, it may sometimes be advisable to draw blood from the peri- 
neum by means of cups or leeches. In the main, however, our 
reliance must be placed upon the measures previously referred to ; 
and, if the patient be seen at a sufficiently early period, relief may 
almost always be obtained within twelve or twenty-four hours, 
either by the catheter, or by rest, the hot bath, opium and tincture 
of the chloride of iron. 

No definite rules can be laid down to determine how long, in cases 
of retention of urine, it is safe to defer puncture of the bladder. 
Each case must be decided by itself from a consideration not only 
of the time retention has lasted, but also of the patient's age, strength, 
and general condition, the urgency of his symptoms, the danger of 
rupture of the bladder or urethra, and the risk of injury to his kid- 
neys. Mr. Thompson has the following excellent observations on 
this point : " There are some surgeons who appear to think as long 
as a patient, under the influence of complete retention, presents no 
very urgent constitutional symptoms, it matters little how much his 
bladder be distended, an almost indefinite amount of endurance 
being ascribed to that organ. That this is very great, is not to be 
denied, and the extreme -rarity of rupture from this cause, which at 
length takes places, as we have seen, rather by ulceration than by 
mechanical extension of its coats, is invariably referred to as evidence 
in favor of such an opinion. But it is certain that very mischiev- 
ous consequences may result from extraordinary distension (rupture 
of the urethra and extravasation of urine being passed over, as suffi- 
ciently obvious), in its effects upon the kidney, not merely in the 
way of temporary interference with the performance of its function 
as a depurating organ; but in the lasting injury it is conceived that 



318 STRICTURE OF THE URETHRA. 

a few hours of extreme pressure and dilatation may exert on its 
structure. This is so much the more readily susceptible of injury, 
as compared with the bladder, as the secreting organ exceeds the 
muscular reservoir, in complexity, delicacy, and intricacy of con- 
struction. We may not, therefore, continue safely our baths, opium, 
purgation, &c, to the extreme limit of endurance on the part of the 
bladder. Our care for the patient must extend beyond that point, 
and if from his history or condition we have reason to believe in 
the existence of organic renal disease, or only to suspect its presence, 
we shall not be warranted in quietly waiting beyond the time neces- 
sary for the exhibition of appropriate medicinal treatment, and the 
careful use of the catheter, for all of which a very few hours will 
suffice ; supposing, it is of course understood, that his powers of 
life at first permitted of the pursuance of that course." 

But while admitting the importance, and even the necessity of 
resorting to an operation, when such interests are at stake, it must 
not be supposed that the cases in which it is required are numer- 
ous. It would probably be very near the truth to say, that is never 
necessary when the patient has from the first been under the care 
of an intelligent and competent surgeon; and that retention can 
always be relieved, within a certain period of its commencement, 
by other and milder measures. Unfortunately assistance is not 
always sought from those competent to give it, until this period has 
been passed either in neglect or mismanagement. 

It having been decided that an operation is necessary, four 
methods are at the option of the surgeon : puncture of the bladder 
by the rectum ; opening the urethra through the perineum ; punc- 
ture above, and puncture through the symphysis pubis. "Forcing 
the stricture" is sometimes enumerated as a fifth method, but is 
justly discarded from modern surgery. Puncture of the bladder 
through the perineum is also obsolete. 

Puncture by the Eectum. — This operation is generally admis- 
sible, readily performed, comparatively safe, affords the most speedy 
relief, and is consequently the one most frequently adopted. It is 
inadmissible in case the prostate is much enlarged from hyper- 
trophy or the presence of a tumor, on account of the danger of 
wounding this body; also if the bladder be much contracted, since 
the trocar may perforate its anterior as well as posterior wall. 
Compared with opening the urethra in the perineum, it has the dis- 



PUNCTURE BY THE RECTUM. 



319 



advantage of not aiming at the relief of the stricture as well as of 
the retention; but this is in a measure compensated for by the 
facility with which the obstruction generally yields to dilatation 
when once an artificial outlet from the bladder has been established, 
and the urethra is no longer irritated by the passage of urine. 

Eecto-vesical puncture may be performed with an ordinary curved 
trocar and canula, about eight inches in length, but it is an advan- 
tage to have the former grooved, so as to indicate with certainty by 
the flow of urine when the point has entered the bladder. 



Fig. 31. 



Fig. 32. 




Fig. 31. Side view of canula and trocar. 1. Eye in the former communicating with the groove in 
the latter. 2. Rings for the purpose of attachment. 3. Channel for the escape of urine 

Fig. 32. Trocar seen on its convex aspect, and showing the groove, which is converted into a tube 
by insertion in the canula. (After Phillips.) 

The patient is to be placed as in the operation for lithotomy, with 
an assistant supporting each extremity. The lower bowel having 
been emptied by an enema, the surgeon introduces his left forefinger, 
well oiled, into the rectum, and feels for the recto- vesical wall just 
back of the posterior margin of the prostate. A tap upon the 
hypogastric region with the opposite hand should communicate a 



320 



STRICTURE OF THE URETHRA, 



sense of fluctuation to the point of the finger in the rectum, and 
this is to be regarded as indispensable before proceeding with the 
operation. The canula and trocar are now to be introduced along 
the finger as a guide, and, while an assistant compresses with both 
hands the lower part of the abdomen, the point is directed forwards 
exactly in the median line, and, by depressing the handle, made to 
penetrate into the bladder, the accomplishment of which may be 
known by its freedom in this cavity. The canula, carefully kept 
in place during the withdrawal of the trocar, is to be fastened by 
a T -bandage, and may be retained until the permeability of the 

Fig. 33. 




Rectovesical and supra-pubic puncture. (After Phillips.) 



urethra is re-established. The risks of this operation are : wound- 
ing the peritoneum or vesiculae seminales ; consequent peritonitis, 
or inflammation of the appendages and substance of the testicle ; 
persistence of the opening; and abscess between the rectum and 
bladder. In practice, however, these results rarely follow. The peri- 
toneum is too high up to be much exposed, and the vesiculae semi- 
nales may be avoided" by adhering closely to the median line. The 



OPENING THE URETHRA. 321 

recto-vesical puncture has been known to remain fistulous for life, 
but generally exhibits a strong tendency to close ; and the formation 
of abscess is rare. This operation has been a favorite one with 
Mr. Cock, of Guy's Hospital, London, who has performed it in 
twenty-four instances, and has seen it performed in some fourteen 
others. He speaks of it in very high terms in the Medico- Chirur- 
gical Transactions, vol. xxxv., where he also gives a plate of a 
trocar, capable of expansion at its extremity, to avoid its slipping 
from the bladder. 

Opening the Urethra. — An incision into the urethra, which 
may be made to include the stricture, and thus lay the foundation 
for subsequent treatment of the latter, is undoubtedly the most 
advisable operation for the relief of retention, whenever the oper- 
ator possesses the requisite skill and anatomical knowledge, and 
provided the perineum be not too deep, nor its tissues too much 
altered from their normal condition. There are two methods of 
performing this operation. 

In one, which is identical with perineal section already described, 
considerable difficulty and delay are often encountered in finding 
the canal back of the obstruction, owing to the thickening and 
oedema of the perineal tissues. 

In the other, the knife is at once directed upon the urethra pos- 
terior to the stricture, without any previous attempt at division of 
the latter, which may afterwards be accomplished or not at the sur- 
geon's option. This method was favorably mentioned by Mr. Lis- 
ton, 1 and highly recommended by the late Mr. Guthrie. 2 The same 
preparation of the patient is to be made as for rectal puncture. 
The left forefinger is then introduced into the rectum, and a narrow, 
sharp -pointed bistoury, held in the opposite hand, with its back 
towards the bowel, made to penetrate the superficial tissues of the 
perineum to the depth of about an inch a little above the verge of 
"the anus, and, cutting upwards in the median line, to form an inci- 
sion an inch and a half to two inches in length. Fluctuation may 
often be detected by a finger inserted in the wound thus made, espe- 
cially if -the patient be directed to strain; and, when present, will 
serve to guide the point of the knife, which should open the ure- 
thra back of the obstruction, in the membranous portion, or possibly 

1 Practical Surgery, 4th ed., p. 484. 2 Lettsomian Lecture, 1851. 

21 



322 STRICTUEE OF THE URETHRA. 

as far back as the apex of the prostate. Before withdrawing the 
blade, a director should be passed into the bladder to facilitate the 
subsequent introduction of a female catheter, which, in case the 
operation is to rest here, must be fastened in place by a bandage ; 
or a probe may be insinuated through the stricture from behind 
forwards, to meet a catheter introduced from the meatus, and the 
obstruction divided upon it ; when the subsequent steps will be the 
same as after perineal section. 

Puncture above the Pubes. — This operation, which was a 
favorite with Abernethy, and according to Dr. Wilmot, 1 is prac- 
tised by Dublin surgeons in preference to recto-vesical puncture, 
has not been so generally adopted in this country as the pre- 
ceding methods. It is entirely inadmissible when the bladder is 
contracted, and difficult of performance when the patient is corpu- 
lent ; though in spare subjects, with the bladder much distended, 
its execution is very easy. The chief danger attending it is from 
infiltration of urine, which should be guarded against by making 
a free external incision, and by leaving the canula in place for 
twenty -four or thirty-six hours, and until lymph has been effused 
around it, before substituting a gum-elastic instrument. Fatal re- 
sults have sometimes ensued from sloughing of the edges of the 
wound, and also from perforation of the peritoneum. 

In performing this operation, the patient should be placed in a 
semi-recumbent posture, with the hair shaved from the pubes ; an 
incision is to be made above the symphysis involving the integu- 
ment and cellular tissue to the extent of about two inches in a ver- 
tical direction ; the pyramidal muscles may now be separated with 
the handle of the scalpel, and the bladder felt for by a finger intro- 
duced into the wound ; the trocar, either straight or slightly curved, 
with its concavity downwards, should be inclined towards the lower 
portion of the sacrum, and a gum-elastic catheter substituted for 
the canula at the end of one or two days. 

Puncture through the Symphysis. — This operation has been 
too infrequently practised to admit of an expression of opinion 
regarding it. It was first proposed by Dr. Brander, 2 in 1825, and 

1 Stricture of the Urethra, 1858. 

2 Seances de l'Athenee de Med., Paris, 1825 ; referred to by Thompson. 



TREATMENT OF EXTRAVASATION. 323 

since performed by him; by Dr. Leasure, 1 of New Castle, Pa., and 
a few others. Its execution is very simple, consisting merely in 
introducing a trocar, by a rotatory motion, either with or without 
a previous incision through the integument, between the pubic 
bones, in the direction of the promontory of the sacrum, and after- 
wards inserting a piece of flexible catheter through the canula. 
Should its safety be proved by farther experience, it will possess 
the advantage, as suggested by Dr. Leasure, of enabling the sur- 
geon, in the absence of other instruments, to relieve retention by 
means of a simple hydrocele trocar. 

TREATMENT OF EXTRAVASATION. 

The general principles upon which the treatment of extravasation 
of urine is to be conducted are: To give free exit by incisions to 
the escaped fluid and disorganized tissues; to support the vital 
powers by nourishment and stimulants ; to remove and render inert 
the noxious products of decomposition by cleanliness and antisep- 
tics. At the earliest moment that any external symptoms of ex- 
travasation can be detected — nay, before this, if constitutional shock 
and deep-seated pain lead to the suspicion of the escape of urine, 
although its presence behind the deep perineal fascia be indicated 
by no sign appreciable upon the surface — a free incision should be 
made in the median line of the perineum, where there is but little 
danger of wounding important vessels. When the extravasation 
has attained more superficial parts, numerous incisions are required 
in the scrotum, and wherever else there is distension and a tend- 
ency to sloughing or gangrene. 

We are generally called upon to sustain the sinking powers of 
life by the free exhibition of nourishment and stimulants; as beef 
tea, brandy, milk punch, carbonate of ammonia, quinine, etc. Opium 
is of value when there is much pain or nervous irritability. Nothing- 
can be done for the relief of the stricture during the continuance 
of the shock consequent upon rupture, but usually, as this passes 
off, catheterism may be successfully performed. In case this cannot 
be accomplished, and if the bladder he found on percussion to be 
still distended, owing to the small size of the rupture, it is desirable 
to resort to puncture at once, or to extend the incision in the peri- 

1 Am. Journ. of the Med. Sci., April, 1854, p. 403. 



324 STRICTURE OF THE URETHRA. 

ileum to the urethra behind the obstruction. The discharge is fetid 
and ammoniacal from the first, and especially so as the disorganized 
tissues are cast off by suppuration ; hence frequent ablutions, poul- 
tices with the addition of Labarraque's solution, or bags of pow- 
dered charcoal, and antiseptic lotions are required. 

TREATMENT OF URINARY ABSCESS AND FISTULA. 

Urinary abscess, as already observed in the present chapter, may 
arise from ulceration of the urethra and consequent escape of urine, 
often in minute quantity, into the cellular tissue, in which case it 
communicates with the canal from the outset ; or it may be pro- 
duced by simple irritation of the neighboring parts, and, although 
isolated at first, eventually open into the urethra. In both cases 
the sooner the abscess is evacuated by external incision, the better ; 
in the former, in order to quiet the constitutional disturbance which 
ordinarily ensues, and prevent the extension and burrowing of 
matter ; in the latter, to effect the same purpose, and also to avoid, 
if possible, any lesion to the urethral walls and the formation of 
urinary fistula ; for when once the urine has found an abnormal 
outlet, it acts as a constant irritant, and renders difficult the closure 
of the passage either by nature or by art. When matter is pent 
up behind the triangular ligament, it is often exceedingly difficult 
to detect its presence by external examination ; there is usually, 
however, even in obscure cases, some degree of hardness and tender- 
ness on pressure, and if its existence is rendered probable by the 
general symptoms, as a chill, nausea, rapid pulse, etc., an incision 
should at once be made in the median line of the perineum in front 
of the anus ; even if pus be not at first found, a passage will be 
formed for its subsequent exit, and the tension of the parts will be 
relieved. In some exceptional cases, urinary abscess assumes a 
chronic character and is attended by little febrile excitement or 
inconvenience ; thus, a small tumor, formed by an abscess commu- 
nicating with the urethra, sometimes exists for months before being 
discovered by the patient or surgeon, unless a careful examination 
of the perineum be made. 

Urinary fistulse, in most cases, contract and close spontaneously 
when the stricture has been thoroughly dilated, especially if the 
general condition of the patient be maintained at a proper standard 
of health. Assistance may be derived from stimulating applica- 



TREATMENT OF URINARY ABSCESS AND FISTULA. 325 

tions to the sinus ; as of nitrate of silver, nitric acid, tincture of 
cantharides or iodine, etc. The end of a probe may be coated with 
nitrate of silver and passed along the fistulous track ; one of the 
tinctures just mentioned, either pure or diluted with water, may be 
injected; and plugs of compressed sponge may occasionally be 
inserted to advantage. Fistulas in front of the scrotum frequently 
require plastic operations, a description of which may be found in 
works on general surgery. 



PAET II 



THE CHANCROID, ITS COMPLICATIONS; 



AND SYPHILIS 



CHAPTER I. 

INTRODUCTORY REMARKS. 

Syphilis is one of the class of diseases called " infectious," the 
characteristics of which are the following : — 

1. The presence of a morbid poison or virus, which transmits 
the disease from one individual to another. 

2. The immunity which one attack generally confers against a 
second. 

3. A "period of incubation," during which the virus is latent 
and gives no external manifestation of its presence in the system. 

4. A degree of order and regularity in the evolution of the 
symptoms. 

It will be well to take a general view of syphilis under each of 
these aspects before proceeding to consider its various symptoms 
in detail. 

SYPHILITIC VIEUS. 

The existence of a syphilitic virus has sometimes been called in 
question, 1 but at the present day is established beyond a doubt. 

1 Chiefly by the following authors : Bru, Methode Nouvelle de traiter les Ma- 
ladies Veneriennes par les gateaux toniques mercuriels, t. i., chap. 3, p. 45. Paris, 
1789. Carox, Nouvelle Doctrine des Maladies Veneriennes. Paris, 1811, p. 33. 
Richoxd des Brcs, De la Non-existence du Virus Venerien. Paris, 1826, t. i. p. 76. 
Jourdax, Traite complet des Maladies Veneriennes, t. i. p. 388. 



328 INTRODUCTORY REMARKS. 

The thousands upon thousands of successful inoculations performed 
by Kicord and others, including those employed in the modern 
practice of syphilization, as well as the daily experience of every 
surgeon, demonstrate that in syphilis there exists a contagious ele- 
ment, by means of which the disease is communicated ; and though 
this morbid poison has never been detected by the senses, the 
microscope, or chemical analysis, its presence is fully proved by its 
effects. An ardent investigator has occasionally imagined himself 
the fortunate discoverer of the essence of this hidden principle, but 
time has invariably shown his error. It has frequently been re- 
garded as a caustic, by some of an acid, by others of an alkaline 
nature. Didier 1 supposed it to consist in minute worms, which 
were constantly multiplied by the process of reproduction, and thus 
propagated the disease ; while more recently Donne has ascribed it 
to the vibrio lineola, an animalcule often found in pus which has 
been exposed to the air. The latter idea, however, is disproved by 
the fact, that the vibriones in virulent pus may be killed by the 
addition of a very weak acid, and yet the power of contagion be 
preserved; moreover no animalcules can be detected in the inocu- 
lable matter of virulent buboes when first opened, and infusoria 
may be found in any purulent secretion, which for a short time has 
been exposed to the air. Again, an attempt made by M. Castano, 2 
in 1855, to prove that syphilis is due to the introduction, germina- 
tion, and development within the system of a parasitical fungus, 
was equally unsuccessful. Thus the essential element of this dis- 
ease has always remained concealed, and probably always will, 
until our knowledge in general of the principle of life and the 
nature of disease is very much greater than now. 

IS THERE MORE THAN ONE KIND OF SYPHILITIC YlRUS ? — The 

unity or duality of syphilis — for no one at present claims that 
there are more than two affections comprehended under this name, 
as commonly employed — has of late years been the chief topic of 
discussion, in the surgical world, connected with venereal; and its 
importance with reference to all the remaining portions of this 
work demands for it special attention. A few preliminary remarks 
are necessary to the proper understanding of this subject. 

1 Dissertation Med. sur les Maladies Veneriennes, 7 e edit., Paris, 1710. 

2 Seance de l'Acadeinie des Sciences de Paris, 26 Fev. 1855; Gaz. des Hop., 
1855, p. 107. 



SYPHILITIC VIRUS. 329 

For a long period prior to the great revolution, which, during 
the last ten years, has taken place in the generally received opinion 
respecting the unity or duality of the syphilitic virus, it had been 
a matter of common observation that some chancres, even when 
not subjected to treatment, were limited in their action to the part 
upon which they were situated and its immediate neighborhood ; while 
others were followed by infection of the general system. Mr. A., 
for instance, would have a chancre upon the penis and a suppurating 
bubo in the groin, but, after these were healed, no further trouble; 
while Mr. B. would contract a primary sore, which would be fol- 
lowed by a train of constitutional symptoms, extending over a 
period of years, and perhaps affecting his offspring. This remark- 
able difference was explained on the ground of a diversity in the 
constitutions of the two individuals. The seed was supposed to be 
the same in both cases, but some peculiarity of soil in which it was 
implanted produced a different mode of germination. There was 
an unknown, something in the system of Mr. A. which protected 
him from constitutional infection, while the absence of the same in 
Mr. B. exposed him to it. If either of these men should communi- 
cate his chancre to a woman, her primary sore, it was thought, 
would be attended by systemic syphilis or not, according to her 
peculiar idiosyncrasy, and independently of the source from which 
the virus came. 

The unsatisfactory nature of these views had attracted attention 
and awakened doubts of their correctness in the minds of several 
surgeons. Hunter devotes Part VII. of his work on Yenereal to 
a consideration of " Diseases resembling the Lues Yenerea, which 
have been mistaken for it," and which he is often evidently at a 
loss to classify. But although frequent misgivings as to the cor- 
rectness of his views are to be found in his writings, he still main- 
tained that "there is no difference in the kind of matter, and no 
variation can arise in the disease from the matters being of different 
degrees of strength; the variations of the symptoms in different 
persons depend upon the constitution and habit of the patient at 
the time." 1 Abernethy was also at a loss to account for many 
syphilitic phenomena, and especially for the development or non- 
development of constitutional syphilis after primary sores which 
closely resemble each other. In his work entitled " Surgical Dis- 

1 Ricord and Hunter on Venereal, 2d edition, p. 47. 



330 INTRODUCTORY REMARKS. 

eases resembling Syphilis," when speaking of venereal ulcers, he 
says : " It is from their effects "upon the constitution alone that we 
can judge whether they are syphilitic or not." (p. 59.) 

Carmichael, 1 in 1814, took a decided stand in favor of a plurality 
of poisons, of which he admitted four, but he believed that they 
were all capable of affecting the constitution, though some were 
susceptible of spontaneous cure without mercury. The distinctions 
which he drew were grounded more upon the character of the 
eruption than upon the appearances of the ulcer, as will appear 
from the following summary : — 

" 1. The scaly eruption which appears under the form of lepra 
and psoriasis, and terminates in ulceration, is alone produced by the 
syphilitic primary ulcer, characterized by its slow progress, and its 
indurated edge and base ; and we find that both local and constitu- 
tional symptoms yield with almost invariable certainty and celerity 
to the action of mercury. 

" 2. The papular eruption which terminates in exfoliation of the 
cuticle may either be occasioned by the smooth superficial ulcer, 
without induration or ulcerated edges, or by a purulent discharge 
from the surface of the glans and prepuce (balanitis) ; or, thirdly, 
by a gonorrhoea virulenta ; and we have found that these different 
species of the same disease are alike capable of a spontaneous cure, 
or of being removed by external astringent applications ; and that 
the constitutional disease they produce is, like the primary, also 
capable of a spontaneous cure, which is promoted by antimony and 
decoctions of the woods. 

" 3. The pustular eruption which terminates in ulcers, covered by 
crusts, is either occasioned by the phagedenic or sloughing ulcers. 
These distinctive venereal complaints, in their primary stage, are 
best treated by such means as subdue inflammation and sympto- 
matic fever, and by anodyne medicines, such as cicuta and opium. 
In their secondary stages, the decoctions of the woods, antimony, 
and mercurial salts, in alterative doses, are the means most to be 
depended upon ; but change of air, and such measures as may tend 
to strengthen the constitution, are also of unquestionable moment. 

" 4. The tubercular eruption which terminates in deep, irregular 
ulcers, has been traced, in one instance only, to a primary sore, which, 
from the manner it undermines the skin, has been named the bur- 

1 Essay on the Venereal Diseases which have been confounded with Syphilis. 



SYPHILITIC VIRUS. 331 

rowing ulcer. But until other cases concur to demonstrate this 
connection, it would be premature to conclude that the one always 
occasions the other. The treatment is the same as for the phage- 
denic ulcer. 

"5. The diseases likely to be confounded with syphilis, which 
arise spontaneously from a disordered state of the constitution, fre- 
quently assume the form of the tubercular eruption. But after 
ulceration, the sores do not continue so extensive, jagged, and ob- 
stinate, and particularly under the means recommended, as those of 
venereal origin. Treatment : nitrous acid, the woods, and alterative 
doses of mercury." 

These views were never generally adopted, even in Dublin, where 
Carmichael resided, and after a brief notoriety were almost entirely 
forgotten. 

But Eicord appears to have had the clearest anticipations of the 
discovery which was destined to emanate from his "school," or from 
among his pupils and followers. In the absence of proof to the 
contrary, this surgeon advocated, in general, the unity of the syphi- 
litic virus, and explained its different effects on the ground of con- 
stitutional differences already referred to ; but Mr. Victor de Meric 1 
states that Eicord remarked to him many years ago : " You may 
rest assured that some day distinct origins will be found for the 
infecting and non-infecting chancres;" and in the first edition of his 
Letters on Syphilis, published in 1851 (p. 257), when referring to 
the fact that in experiments upon syphilization, inoculation of the 
matter of soft chancres had always produced soft chancres, while in 
the single instance that pus from a hard chancre had been em- 
ployed, a hard chancre was the result, this author says : " If these 
results were constantly obtained, we should be forced to conclude, 
that there are differences in syphilis which do not depend alone 
upon the condition of the individual upon whom the cause acts, but 
upon differences in the cause itself." 

"With this brief history of opinion regarding this important ques- 
tion, we come down to the year 1852, when the first successful 
assault was made on the old doctrine of idiosyncrasies and tempera- 
ments, and led to its final overthrow and the establishment of the 
duality of the chancrous virus. At this time, M. Bassereau, a former 
pupil of Eicord, published his "Traite des Affections de la Peau, 

1 Lettsomian Lectures, 1858, p. 9. 



332 INTRODUCTORY REMARKS. 

Symptomatiques de la Syphilis," a work characterized throughout 
by such originality of thought and accuracy of investigation that 
its perusal is essential to every one who would be thoroughly in- 
formed on venereal diseases. Although nominally a treatise upon 
syphilitic eruptions alone, many other subjects connected with 
syphilis are discussed, and among them the unity or duality of the 
syphilitic virus. Justice to the author, the intrinsic and historical 
interest of his remarks, the manly and cogent style of his reasoning, 
and the absence, so far as I am aware, in the English language, of 
any suitable exposition of his views expressed at this early day, 
demand a somewhat extended quotation, which I shall give in the 
form of a free translation, with such abridgment as my limits as to 
space require. 

It is necessary to premise that this question is discussed by M. 
Bassereau in his chapter on syphilitic erythema, which, being one 
of the earliest symptoms of constitutional syphilis, affords a better 
opportunity for tracing the connection between primary and second- 
ary lesions than any other. The cases of erythema, to which fre- 
quent reference is made, number 170, if we exclude twenty-eight 
in which the absence of information regarding the primary ulcer 
precluded any comparison. 

In the tenth section of the chapter upon this subject, entitled : 
"Kecherche des causes qui ont pu determiner le developpement de 
1'ery theme, c'est-a-dire la generalization des symptomes syphilitiques 
dans l'economie," M. Bassereau says : — 

" There can be no question of the fact that there are chancres 
which may be treated by the most simple remedies without the 
employment of any mercury whatsoever, and yet never be followed 
by the symptoms of constitutional syphilis. Any one may convince 
himself of this truth by inquiring of old men, many of whom will 
state that they had chancres several times in their youth, which 
were treated with simple cerate, lint, or other means destitute of 
specific action, and, though they have never taken mercurials, there 
has not been the slightest appearance of constitutional syphilis 
during the thirty or forty years which have since elapsed. Many 
persons also will repeatedly have chancres and escape infection, but 
will finally contract another which will be followed by a syphilitic 
eruption. Why this difference ? What should limit the action of 
the chancre in the one case and in the other extend it to the whole 
system ? This is an interesting problem, and I will proceed to give 



SYPHILITIC VIRUS. 333 

the results of my attempts to solve it. Let no one who is wont to 
pay respect to opinions which have received the stamp of authority 
take umbrage at the novelty of the propositions which I am about 
to present, or be hasty in rejecting them. The question at issue is 
so important that it deserves serious examination. It is not to be 
decided by an appeal to the vague impressions left on the mind by 
former experience, or by the doctrines of this school or that ; it can 
only be settled by new investigations undertaken for the very pur- 
pose. I ask therefore of unbiassed men to devote the necessary 
time to verify the facts which I am about to present, and to give 
them their most scrupulous attention. 

"Among the causes which I have investigated, I have endeavored 
to ascertain if age has any influence in the extension of syphilis to 
the general economy, and I have satisfied myself that it has none. 
From birth to the most advanced years, man may have chancres, 
which, at any age, may be followed by constitutional syphilis ; and 
though infection is more common among the young, it is simply 
because they are more exposed. Sex is equally devoid of influence. 
Eicord states that chancres are less frequently indurated in women 
than in men, which is equivalent to saying that women are less 
liable to constitutional syphilis, since it can easily be shown that 
infection follows in most cases indurated chancres. I do not believe, 
however, that Eicord carries the induction thus far. For my own 
part, I think that the rarity of induration in women is only appa- 
rent. Indeed, in an examination of the same number of chancres 
in the two sexes, I have found nearly the same proportion indurated 
in the one as in the other ; with this difference, that the induration 
was generally poorly marked on the vulva, while it was very de- 
cided upon the penis. Just as the skin of various parts of the 
body is not equally susceptible of the development of induration, 
so this .symptom is less frequent iipon the genital organs in women 
than in men. But women are not on this account less exposed to 
constitutional syphilis. Though fewer persons of this sex are 
affected with this disease, it is because the number who are addicted 
to debauch is incomparably less than of men; whence venereal 
affections of all kinds, constitutional syphilis included, are less com- 
mon among them, and the difference cannot be attributed to mere 
sex. 

"Again, idiosyncrasy will not explain the fact that a chancre 
produces only local effects in one person, while in another it infects 



334 INTRODUCTOEY REMARKS. 

the system at large. This is proved by the number of persons 
who, after having numerous simple chancres, contract another which 
becomes indurated and is followed by constitutional manifesta- 
tions. 

" Can such different results from two acts of contagion by a virus 
reputed the same be accounted for by the changes which frequently 
take place in the constitution, and by virtue of which a man is not 
affected in the same manner by the same agent at times very nearly 
approximated? Doubtless such dissimilar effects might depend 
upon the particular disposition existing at the time of contagion ; 
but this explanation is admissible only in default of a better, espe- 
cially as it is opposed to what we know of the action of specific 
causes, which always tend to produce the same results. 

"I have carefully studied the temperament and constitution of 
persons affected with syphilitic erythema, in order to discover if 
any one of these organic modifications of the system might not 
influence the development of constitutional syphilis, but such 
inquiry has led to no positive result. I have found all tempera- 
ments affected in nearly equal proportion ; none can therefore be 
regarded as peculiarly conducive to the extension of syphilis 
throughout the economy; and the same may be said of difference 
of constitution. 

"An insufficient amount or the bad quality of food, which is a 
powerful aggravating cause of syphilitic symptoms, has been so 
rarely observed in the cases of erythema which have come under 
my notice, that it is impossible to ascribe to it the development of 
general syphilis. The abuse of alcoholic stimulants, changes of 
temperature, and intercurrent diseases appear to have had no more 
effect. I have merely noticed that chancres contracted during warm 
weather are more rapidly followed by syphilis than during cold. 

"The above remarks clearly show that neither age, sex, idiosyn- 
crasy, temperament, constitution, hygienic influences, nor coexisting 
diseases which might be supposed to have depressed the system at 
the time contagion took place, can, each by itself, be regarded as the 
determining cause of infection ; and if we group them all together 
instead of considering each singly, my statistics will show that they 
will not account for one-third of the cases of constitutional disease. 
The better to appreciate the etiological value of these influences, I 
have examined the condition of those persons whose chancres, in 
spite of the absence of all treatment capable of retarding or destroy- 



SYPHILITIC VIRUS. 335 

ing a tendency to secondary symptoms, have not been followed by 
constitutional syphilis. I have compared one hundred such cases 
with an equal number of patients affected with syphilitic erythema, 
and have found in each nearly the same proportion of lymphatic 
temperaments, feeble constitutions, bad hygienic influences, etc., 
thus confirming my opinion of the necessity of searching for other 
than physiological and hygienic causes of the generalization of 
syphilitic manifestations. 

"I have also sought for the solution of this question in the chan- 
cre itself. I have endeavored to ascertain if repeated acts of con- 
tagion might not favor the appearance of secondary symptoms. 
On examination of the cases cited, I found that in 112 cases the 
eruption appeared after several successive chancres, and in 86 after 
a single chancre. Notwithstanding the predominance of the former, 
it cannot, I think, be admitted that the repetition of primary symp- 
toms is the cause of constitutional infection. The idea that the 
action of a virus must be accumulated to produce its utmost effect 
is but little in accordance with the medical knowledge we already 
possess. In a number of my cases, also, there was so long an in- 
terval between the chancres that it appears to me difficult to attri- 
bute to the first contagion any influence whatever in the production 
of the constitutional syphilis which followed the last exposure. 

"Again, I have inquired if individuals affected with several 
chancres at one time, were not more exposed to constitutional in- 
fection than those having only one, and who consequently bore 
upon their persons a smaller surface secreting contagious matter ; 
but I found this could not be the case, for of the 170 instances of 
syphilitic erythema, 141 had had but one, and only 29 multiple 
chancres ; whence I conclude that neither the plurality of primary 
sores nor the extent of the secreting surface can be regarded as the 
cause of the constitutional manifestations which sometimes appear. 
These results are analogous to those obtained by Kirkpatrick, 
Dimsdale, and Gatti in experiments with the virus of variola, from 
which it appears that there is no connection between the number 
of inoculated points and the copiousness of the consecutive eruption. 
Girot even observed that the eruption- of variola was milder and 
more discrete after inoculating in six places than when only two 
punctures were made. 

"An analysis of these cases of syphilitic erythema shows that 
the development of constitutional syphilis is not affected by the 



336 INTRODUCTORY REMARKS. 

situation/ degree of ulceration, or duration of the primary sores. 
General symptoms may supervene, on whatever part of the body a 
chancre is situated ; and the intensity of the former is not increased 
when the primary ulcer is at a distance from the genital organs, as 
was once supposed by Boerhaave. A decided tendency to extend 
by ulceration is also innocent of the development of constitutional 
syphilis ; for I have often seen the mildest and most superficial ero- 
sions followed by infection, while phagedenic sores proved in- 
nocuous. Chancres which last for a long period are not more likely 
to terminate in secondary syphilis than those which cicatrize within 
a moderate or short space of time, as may also be seen from an 
examination of these 170 cases. 

" On the other hand, induration is so frequent a symptom of these 
primary ulcers 2 that it is impossible not to admit that it bears an 
intimate relation to the syphilitic erythema which ensued. But 
even if it could be shown that all infecting chancres are indurated, 
must we necessarily say that induration is the cause of infection ? 
By no means ; for this would only be avoiding the question instead 
of solving it, since the cause of the induration would still remain 
to be discovered. 

"Finally, in my investigations I have endeavored to ascertain if 
any relation existed between the symptoms presented by my patients 
and those of the persons from whom they contracted their disease. 
Such inquiry is often difficult, for men are frequently infected by 
women whom they never see but once, and of whose name and 
address they are ignorant. Some have intercourse with several 
women within a short time preceding the appearance of the chancre, 
so that the source of the virus is doubtful ; others refuse to give 
any information with regard to the persons with whom they have 
had connection. In some cases, however, we are able to compare 
the symptoms in the two sexes. Patients often bring to me for 
examination the women who infected them, or else put me in the 
way of visiting them at their homes. Frequently, also, at the 
Hopital des Veneriens, I have found two or three, or even a larger 
number of men who contracted their disease from the same woman, 
either on the same day or at a few days' interval. Finally, in 

1 At the time this was written, the fact that soft chancres are never met with 
upon the head or face was not known. 

2 Of the 170 chancres, 157 were known to be indurated ; in 13 induration was 
doubtful. 



SYPHILITIC VIKUS. 337 

several instances I have seen both a wife and husband, and even 
their children, all affected with syphilis which had been introduced 
into the family through one of its members. 

" These repeated confrontations of persons infected by each other 
— undertaken at first to determine what syphilitic lesions are con- 
tagious and what are not ; to show what symptoms may succeed 
others, and what modifications the same symptom may undergo 
by transmission betAveen individuals of different sex and tempera- 
ment — have led to the discovery of that hitherto mysterious cause 
by virtue of which chancres sometimes limit their action to the 
part on which they are situated and the neighboring ganglia, and 
at other times extend their effect to the system at large and are 
followed by constitutional syphilis. The following propositions 
embody the results obtained from the confrontation of patients 
affected not only with erythema, but also with other syphilitic 
eruptions and primary sores, with those persons from whom their 
disease was derived : — 

"If we compare persons who have had chancres followed by 
constitutional symptoms with those persons who inoculated them, or 
with those whom they in turn have inoculated, we find that all, 
without exception, have had' constitutional syphilis; never, in any 
case, has the action of the chancre been merely local. 

" On the other hand, by the comparison of individuals who have 
had chancres which did not result in general manifestations with 
the individuals who infected them, or with those whom they have 
infected, we find without exception that the latter, equally with the 
former, have had chancres, the action of which was limited to the 
part first inoculated. Thus a chancre followed by constitutional 
syphilis never gives rise to a merely local chancre ; and a purely 
local chancre cannot produce a chancre which will be followed by 
the general manifestations of syphilis. The uniformity of the facts 
which have come under my observation — none but apparent ex- 
ceptions having ever been met with — fully justifies me in enun- 
ciating the following proposition as a law : — 

"Whenever a person has a chancre and afterwards constitutional 
syphilis, the generalization of the syphilitic phenomena is first of all 
due to the fact that the person from whom the contagion came had a 
chancre which was necessarily followed by constitutional symptoms. 

" Of thirty -four cases of syphilitic erythema, in which I have 
been able to confront the patients with those who infected them, 
22 



338 INTRODUCTORY REMARKS. 

and in some instances with those whom they had afterwards infected, 
in thirty-one, conformably to the law just enunciated, all the indi- 
viduals thus confronted presented lesions of the same character ; all 
without exception had chancres which were followed by constitu- 
tional syphilis. In only three, from the absence of symptoms of 
general infection, did there seem to be any exception, but indura- 
tion was found at the site of the primary sore, showing that the 
exception was only apparent; moreover, the mercury which had 
been administered for the latter fully accounted for the absence, or 
delay in the appearance, of constitutional manifestations." 

The immutability of these two chancres being thus established 
by clinical experience, it is evidently necessary to admit that they 
constitute two species. The question then remains whether or not 
they bear any relationship to each other. One of two alternatives 
must be true : the virus of each must be the same, but of greater 
intensity in one than in the other ; or there must be two poisons 
totally and radically distinct. 

Two years after the publication of M. Bassereau's work, the first 
mentioned supposition was adopted by M. Clerc, 1 another pupil of 
Eicord, who maintained that the virus of the soft was a modifica- 
tion of that of the hard chancre ; the former bearing the same rela- 
tion to the latter that varioloid does to variola, and the false to the 
true vaccine pustule ; and in accordance with this view the name 
of "chancroid" was given to the first, while the term chancre was 
exclusively reserved for the second ulcer. This modification, as 
M. Clerc believed, was produced by the passage of the virus through 
the system of a person already under the influence of the syphilitic 
diathesis ; the poison, thus materially changed in its nature, was 
capable of indefinite transmission by contagion, but could never 
recover its original power of infecting the constitution ; just as the 
false vaccine pustule may sometimes 2 (not always) be inoculated 
from one individual to another without affording protection against 

1 Memoire du Chancro'ide Syphilitique, Paris, 1854. 

2 The theory of M. Clerc appears to be as defective in its analogies as in the 
absence of direct proof, for the false vaccine pustule is not always perpetuated as 
such ; and there is abundant evidence — cited very fully by M. Fournier (Lecons 
sur le Chancre, p. 168) — to show that varioloid may give rise to variola and vice 
versa in subjects unprotected by vaccination or previous attacks. The assumed 
permanence of these forms of disease, when once established, cannot therefore be 
sustained. 



SYPHILITIC VIKUS. 339 

variola, or, in other words, without exerting any influence upon the 
general system. 

M. Clerc's theory was sufficient to explain all the phenomena 
hitherto stated in the quotation from M. Bassereau, and it only 
remained to demonstrate by direct observation whether or not the 
transmission of the syphilitic virus through a system already in- 
fected would produce such modification as was claimed in its nature. 
At the time M. Clerc's essay appeared, the necessary facts were 
wanting to determine this point, but they have since been met with 
and have proved the theory without foundation. In several in- 
stances, a man laboring under the symptoms or diathesis of consti- 
tutional syphilis has contracted a chancre from a woman having an 
infecting chancre, and although, under these circumstances, as will 
be seen hereafter, the chancre in the male closely resembles a soft 
chancre in appearance, yet if it be communicated to a third person 
as yet free from constitutional taint, the result will be a hard 
chancre and general syphilis. "We thus have positive proof that 
no such modification takes place as asserted by M. Clerc ; and his 
theory is at present generally abandoned, although the term " chan- 
croid" is conveniently retained to distinguish the non-infecting 
from the infecting chancre. 

Bassereau regarded the first alternative above mentioned, of 
which Clerc's theory is the only representative, as deserving of 
rejection from the absence of any proof in its favor; and boldly 
advocated the second, viz., that the virus of the soft chancre is 
radically distinct from that of the hard. A careful study of the 
older writers on medicine afforded additional evidence in support 
of this opinion, by showing that simple venereal ulcers have been 
known from the earliest times of which we have any record ; that 
the hard chancre and its consequent constitutional symptoms was 
first observed in the latter part of the fifteenth century, during the 
Italian epidemic; and that for twenty or thirty years afterwards 
these two species of ulcer were never confounded; the duality of 
the chancrous virus is not therefore a modern discovery, but was 
familiar to those who witnessed the first irruption of syphilis into 
Europe. In the introductory chapter of this work, I have already 
given an extended account of these historical researches, which 
have been confirmed by those of Langlebert and Chabalier ; and 
I shall at present merely refresh the reader's memory by stating 
in Bassereau's own words the conclusions at which he arrived. 



340 INTRODUCTORY REMARKS. 

"When we read all that ancient and modern authors have written 
on the diseases of the organs of generation, we find that gonorrhoea, 
chancres, buboes, and vegetations are mentioned as late as the last 
years of the fifteenth century, as diseases requiring only local treat- 
ment ; up to this time there is not the slightest allusion to any 
symptoms consecutive to the diseases of the genital organs. The 
end of the fifteenth century, according to all the contemporary au- 
thors, was marked by the appearance of a new disease. This dis- 
ease commenced by indurated ulcers upon the genital organs, which 
were speedily followed by pustular eruptions over the whole body, 
and by frightful pains in the head and limbs. The physicians who 
were eye-witnesses of the new disease did not at first confound the 
callous ulcers in which it commenced with the ulcers of the genital 
organs which had been known for ages. Thus these two species of 
ulcers occupy in their writings separate chapters, and even separate 
books. But, twenty or thirty years after the appearance of syphilis 
in Europe, many physicians not knowing, as those did who witnessed 
its first ravages, how to distinguish the symptoms by which the new 
disease commenced from those which had no relation whatever with 
it, assumed by degrees the habit of submitting to mercurial treat- 
ment, without distinction, all persons affected with gonorrhoea, 
chancres and buboes ; for it had already become a general practice 
to administer mercury, not only for the purpose of modifying ex- 
isting syphilitic symptoms, but also as a prophylactic agent against 
future symptoms, as soon as the first signs of contagion began to 
appear. The confusion which reigned in practice was soon intro- 
duced into the works of the day; the writers on syphilis in the 
middle of the sixteenth century included, one by one, under the 
name of syphilis all those venereal symptoms which had been 
known from the earliest antiquity, and which the physicians who 
exercised their art in the last years of the fifteenth century had 
taken care to separate from the symptoms of the new disease." 

The attention of the profession being thus directed anew to the 
important question of the unity or duality of the chancrous virus, 
other observers immediately set to work to test the accuracy of M. 
Bassereau's observations, and new facts soon began to appear, all of 
which were found to point in the same direction. In 1856, M. 
Dron 1 was able to collect one hundred and eleven instances of con- 
frontation, including those of Bassereau relating to the hard chancre, 

1 "Du Double Virus Syphilitique," these de Paris, 1856. 



SYPHILITIC VIRUS. 341 

those of M. Clerc relating to the soft chancre, and others relating to 
both varieties furnished by Diday, Eollet, Eodet ; and Founder, and 
in all, without exception, the t}^pe of the ulcer remained unchanged 
in passing from one individual to another. Farther investigations, 
under the supervision of Eicord and with the same result, were 
made by MM. Founder and Caby, who availed themselves of the 
unequalled facilities for such examination afforded by the chief 
venereal hospitals of Paris — one (du Midi) devoted to men, the 
other (St. Lazare) to women — and of the vigilance of the French 
police. These observations were published in detail by M. Four- 
nier in his edition of Eicord's Lecons sur le Chancre?- and also in 
a pamphlet entitled, Recherches sur la Contagion du Chancre, 7, and 
comprise fifty-nine cases of transmission of the infecting, and thirty- 
nine of the non-infecting chancre. The value of many of these cases 
was materially enhanced by the fact that two or more men were con- 
taminated by the same woman, and thus the testimony in favor of 
the duality of the chancrous virus was multiplied. In one, two 
friends, who shared the favors of the same woman having an infect- 
ing chancre, caught, each of them, an infecting chancre followed 
by constitutional symptoms ; and the father of one of them, an old 
man aged seventy -three, had connection with his son's mistress, and 
met with a similar fate. Again, six persons were infected from 
the same source, and the consequences in all were identical, viz., 
infecting chancres and constitutional manifestations. So with the 
non-infecting or simple chancre ; in several of Founder's cases, two, 
three, or four men, bearing simple chancres, were found together in 
the wards of the Hopital du Midi, all of whom ascribed their conta- 
gion to the same woman ; who, on examination, was proved to have 
the same species of primary sore ; and in none did constitutional 
symptoms appear during several months that they were kept under 
observation. 

Thus far in our account of Fournier's investigations, we find that 
they merely confirm the observations of Bassereau, since they all 
relate to the transmission of primary sores between persons free 
from previous syphilitic taint. It remains to be proved what effect, 
if any, is produced in each species of- chancre by being communi- 
cated to a system already under the influence of the syphilitic 
diathesis. The solution of this question was also undertaken by 
Fournier, who found, as regards the simple chancre, that the sore was 

1 Paris, 1858. 2 Paris, 1857. 



342 INTRODUCTORY REMARKS. 

in no way modified; that if, for instance, a woman having a simple 
chancre, communicated it to a man whose constitution was already 
infected with the virus of true syphilis, and he gave the same to a 
woman free from such taint, the resulting sore would in no respect 
be changed in consequence of the general infection of the man 
through whom it had been transmitted. This result might have 
been predicted beforehand, from a consideration of the distinct 
nature of the two kinds of virus, neither of which will directly 
influence the other, any more than syphilis will affect the course of 
gonorrhoea, or vice versa. ' 

With regard to the hard or infecting chancre the results were 
more novel and interesting. A chancre of this species, communi- 
cated to a subject already infected with syphilis, does not present 
its usual characteristics ; it is destitute of specific induration and 
unaccompanied by induration of the neighboring lymphatic gan- 
glia; in short, it so closely resembles an ordinary soft chancre that 
it cannot be distinguished from it by any outward sign. If, how- 
ever, this sore — in appearance a soft chancre, but in reality a hard 
chancre, modified by the constitutional infection of the person bear- 
ing it — be communicated to a third person free from constitutional 
taint, it will resume its normal characteristics, will become indu- 
rated, be accompanied by induration of the neighboring lymphatic 
ganglia, and followed by the general manifestations of syphilis. 

The evidence on which the statement just made regarding the 
infecting chancre is based, is sufficient, though not so great in 
amount as that relating to the transmission of chancres between 
individuals free from constitutional infection ; since facts capable of 
solving the question under consideration are necessarily rare. For, 
in the first place, the virus of an infecting chancre rarely takes effect 
at all upon a subject already infected ; one general attack protecting 
against even local manifestations of the poison, just as vaccination 
is without result upon a system once imbued with the vaccine or 
variolous virus ; and, in the second place, supposing contagion to 
occur, the disease must be again communicated to a person who has 
always been free from constitutional taint. These numerous and 
complex requirements, however, have all been present in seven cases, 
of which Cullerier, 1 Melchior Eobert, 2 and Diday, 3 each observed 

1 Fournier, Contagion du Chancre, p. 57. 

2 Dron, These, already referred to. 

3 Annuaire de la Syphilis, annee 1858, p. 277. 



SYPHILITIC VIKUS. 343 

one, and Fournier and Caby four; and they all concur in showing 
that, contrary to M. Clerc's theory, the virus of an infecting chancre 
is not modified by being communicated to a system already in- 
fected, and although it produces a sore apparently identical with a 
soft chancre, its essential attributes are unchanged. 

Another point to which Fournier directed his attention was 
whether phagedenic ulceration of a chancre is due to any pecu- 
liarity inherent in the virus — a question which the confrontation 
of patients answers in the negative. The origin of phagedena is 
probably complex, being attributable in some cases to noxious 
principles in the primary pus of contagion, more frequently to 
constitutional cachexia in the recipient, and sometimes to both 
causes combined ; but without entering fully into its etiology, it is 
sufficient for our present purpose to say that the virus of phage- 
denic chancres is not a distinct species, since this form of ulcer may 
owe its origin to an ordinary chancre either of the simple or infect- 
ing variety. 

The results thus far attained by comparison of the symptoms of 
those giving and those receiving primary ulcers may be summed 
up in the following propositions : — 

1. Among persons free from previous syphilitic taint, each of the 
two species of chancre is transmitted in its kind : the simple chancre 
as a simple chancre limited in its action to the neighborhood of its 
site; the infecting chancre as an infecting chancre, followed by 
constitutional manifestations. 

2. A primary sore with a soft base, and unaccompanied by indu- 
ration of the neighboring lymphatic ganglia, in a subject already 
infected with syphilis, will, when communicated to a person free 
from syphilitic taint, give rise to a soft or hard chancre, according 
to the nature of the virus which occasioned the first mentioned 
ulcer. 

3. The virus of the non-infecting chancre is a poison distinct 
from that of the infecting chancre. 

4. Phagedenic ulceration of a chancre does not depend upon a 
specific difference in the virus. 

In reviewing the labors, of which a somewhat full account has 
now been given, we find that the duality of the chancrous virus is 
established upon the same evidence as naturalists determine the 
identity of species in the animal and vegetable kingdoms; viz., 
by the immutability of certain traits in successive generations. The 



344 INTRODUCTORY REMARKS. 

" immutability of species" lies at the foundation of all classification 
in natural history ; it is the groundwork upon which the whole 
superstructure rests ; and although we cannot always expect to fol- 
low out the same laws in the arrangement of the protean forms of 
disease that we do in nature, the simple principle referred to is 
unquestionably as applicable to one as to the other ; nay, when pre- 
sent in morbid manifestations, it may be regarded as of the greater 
value, from the very fact of their general inconstancy. The cha- 
racteristics, the immutability of which is relied upon to establish 
the duality of the chancrous virus, are the limitation of the power 
of a chancre to mere local action on the one hand, and, on the other, 
its necessary influence upon the general system ; and no one will 
fail to see that, if these can be proved to be constant, they are suffi- 
cient to establish a distinction of species. 

It should be observed that the external appearance of primary 
ulcers does not enter as an element into this consideration. The 
proof would be equally valid, even if it could be shown that the 
two species of chancre are never distinguishable by any outward 
sign. It is sufficient to establish the fact that the action of the 
virus in one series of cases is local, and in the other general. Na- 
turalists, in many instances, ground their classification of species 
upon differences confined to one period of their existence. The 
young of many forms of animal life closely resemble each other, 
although the adults are widely different. From the study of em- 
bryology alone, Agassiz has derived the most correct system of 
classification which has ever been advanced. While, therefore, as 
will hereafter appear, the soft and hard chancres do present, in 
most cases, differences recognizable by the sight and touch, these 
must be regarded as additional, but not essential, evidence of the 
distinct nature of the two forms ; and their absence, as occurs in 
some instances, and perhaps in all, when the virus of a hard chancre 
is implanted upon a system already infected, does not invalidate the 
proof of the existence of two kinds of chancrous virus. 

The new doctrine upon this subject, which, as shown by Basse- 
reau, is an old doctrine revived, appears to me to occupy an impreg- 
nable position. The confrontations of the observers whose names 
have been mentioned, alone amount to 137, and among them all, 
not a single instance of interchange between the two forms of 
chancre has been met with. Nearly every physician has the oppor- 
tunity to satisfy himself of the truth of this doctrine by personal 



SYPHILITIC VIRUS. 345 

observation ; let him but take note of the not infrequent cases in 
which a husband gives a chancre to a wife whose fidelity cannot 
be called in question, and he will find that they will both escape, or 
both incur constitutional infection. Thus, every one can contribute 
his quota to the statistics on this interesting subject. For myself, 
in a somewhat extended field of observation during ten years of 
practice, I have never seen an instance of interchange of the two 
species of chancre, and I can recall fourteen cases — six of simple, 
and eight of infecting chancres — in which the transmission of each 
in its kind was unquestionable. 

In pursuing these investigations, it is of course necessary to 
guard against all sources of error ; the fact should be well estab- 
lished that the person supposed is really the one who gave the dis- 
ease ; it should be ascertained with certainty that neither the man 
nor woman has been previously infected, otherwise he or she is 
incapable of receiving a second infection ; and the influence of a 
mercurial course in preventing, or more frequently in retarding, 
constitutional manifestations, should be borne in mind. Xor is mer- 
cury the only agent capable of delaying the appearance of second- 
ary symptoms ; the same effect may be produced by a course of 
iodide of potassium, sudorifics, or other medicines which increase 
the excretions from the body. 

The important subject which has occupied our attention is sug- 
gestive of many considerations, of which our limited space will 
permit only a few to be sketched in outline, as follows : — 

1. From the existence of two kinds of chancrous virus, it does 
not follow that there are two kinds of syphilitic virus. The term 
" syphilis" implies not only a local, but a general disease ; conditions 
which are alone fulfilled by the hard chancre, and its consequent 
constitutional symptoms. The soft chancre and its attendant bubo 
should not, properly speaking, be described under the head of 
syphilis, but be considered apart like gonorrhoea. It is also desir- 
able to adopt a different name for this ulcer, as, for instance, the 
term " chancroid," which is already much employed, especially by 
the French, and which will frequently be used in the following 
pages as synonymous with "soft" and "non-infecting chancre." 
The complete separation, however, of these two forms, in describing 
chancres and their attendant symptoms, would perhaps at the pre- 
sent time be objectionable, while yet the new doctrine on this sub- 



346 INTRODUCTORY REMARKS. 

ject is not familiar to all, and I shall, therefore, follow the usual 
course and describe them together. 

2. The distinction which is now drawn between the non-infecting 
and infecting chancres explains in a great measure the variance 
which has long existed with regard to treatment between the " mer- 
curialists" and "anti-mercurialists." The soft chancre, being a 
strictly local disease, requires no constitutional remedies, unless, in 
exceptional cases, as adjuvants to local treatment. Mercury is of 
value only in cases of hard chancre and general syphilis. Since 
the number of soft chancres greatly exceeds the number of hard 
chancres, it is evident that the general results of treatment may be 
made to sustain either the use or disuse of mercury, if exclusively 
applied to both forms in common. 

3. A comparison of the three poisons of gonorrhoea, the soft and 
hard chancre, so far as we are at present able to understand their 
nature, leads to the following conclusions. 

The only property common to them all is their communication, 
for the most part, by contact of the genital organs. 

The poisons of gonorrhoea and of the chancroid are alike in that 
their action is limited and never extends to the general system ; nor 
does one attack afford the slightest protection against a second. 
They differ in that the poison of gonorrhoea may arise spontane- 
ously, while that of the chancroid, so far as we know, never thus 
originates ; that gonorrhoea chiefly affects the surface — true ulcera- 
tion being rarely induced — and, in its complications, most frequently 
attacks parts connected with the original seat of the disease by a 
continuous mucous surface, as the prostate, bladder, and testicle ; 
while the soft chancre, on the contrary, is an ulcer, involving the 
whole thickness of the integument or mucous membrane, and its 
complications are seated in the absorbent vessels and ganglia. It 
would also appear that the poisons of these two affections are 
limited to one common vehicle, viz., pus. Yan Eoosbroeck, on the 
authority of Eollet, has proved by experiment that if the discharge 
of gonorrhoeal ophthalmia be deprived of its pus-globules by fil- 
tration, the remaining fluid is innocuous ; and Eollet states that he 
has obtained like results with the pus of soft chancres. If these 
experiments can be relied on, they prove that the virus is not dif- 
fused throughout the purulent secretion, but is confined to the pus- 
globules which it contains. This conclusion is sustained by the 
fact that neither the poison of gonorrhoea nor that of the chancroid 



SYPHILITIC VIEUS. 347 

ever reaches the general circulation, and it is well known that pus- 
globules are not capable of absorption. When the purulent matter 
of a soft chancre enters the absorbent vessels, as occurs in the 
formation of a virulent bubo, it is arrested by the first chain of 
lymphatic ganglia, and goes no farther. The paint used in tattooing 
is sometimes conveyed to a ganglion in a similar manner; 1 but nei- 
ther in this case nor the former is there complete absorption. 2 

The virus of the hard chancre is alone capable of infecting the 
system at large, and of affording protection by its presence against 
subsequent attacks. Unlike the poisons of gonorrhoea and the 
chancroid, it is not limited to purulent matter, but exists in the 
blood, in the fluids of secondary lesions, in the semen, and probably 
in other secretions. The secretion of one form of the hard chancre 
(the superficial variety), as shown by microscopical examination, is 
often entirely destitute of pus-globules; 3 and the presence of the 
virus in secondary symptoms is proved by their power of contagion, 
and in the semen by the occurrence of hereditary syphilis in the 
offspring when the father is alone infected. « 

There is no opposition whatever between these three poisons ; 
they may all coexist in the same person, who may at the same time 
have gonorrhoea, a chancroid, and a chancre ; hence we may explain 
a case related by Acton in which each of three students contracted 
one of these diseases from intercourse with the same woman on the 
same day. Two of these poisons may be present in the same fluid, 
as when the secretion of a hard or soft chancre mingles with that 
of gonorrhoea; or as in the "mixed chancre" resulting from inocu- 
lation of the same part, either at the same time or successively, by 

1 Virchow has given a beautiful plate of the deposit of pigment matter in the 
axillary gland of an arm, the skin of which had been tattooed, and describes the 
process of absorption as follows : " A certain number of particles find their way 
into lymphatic vessels, are carried along in spite of their heaviness by the current 
of lymph, and reach the nearest lymphatic glands, wbere they are separated by 
filtration. We never find that any particles are conveyed beyond the lymphatic 
glands and make their way to more distant points, or that they deposit themselves 
in any way in the parenchyma of internal organs." {Cellular Pathology, English 
translation, p. 184.) 

2 Rollet, De la Plurality des Maladies Veneriennes, Gaz. Med. de Lyon, No. 8, 
1860. 

3 Mr. Henry Lee believes that the infecting chancre is always an ulcer affected 
with specific adhesive inflammation, and, unless irritated, destitute of pus-globules. 
Of 95 cases examined by the microscope at King's College Hospital, in none was 
the secretion purulent. (Medico- Chir. Trans., vol. xlii. p. 450.) 



348 INTRODUCTORY REMARKS. 

the virus of the chancroid and that of the chancre. The secretion 
of the soft, or that of the hard chancre and its consequent secondary 
symptoms, may also mingle with other animal poisons, as the vac- 
cine virus, and each will produce its usual effects unmodified by 
the presence of the other. 

Apparent exceptions to some of the above statements are met 
with in the practice of syphilization, and will be explained in an- 
other chapter. 

The severity of the symptoms produced by syphilis on its first 
appearance in the latter part of the fifteenth century, compared with 
its greater benignity at the present day, affords some ground for 
believing that its virus is slowly but gradually losing in intensity, 
in the same manner as the vaccine virus is supposed to become 
weaker after many successive removes from the cow. This fact 
was noticed by Astruc 1 in the middle of the last century, who 
says : " Whatever might formerly be the power and efficacy of the 
venereal disease when it was new and in vigor, while the undivided 
poison violently effervesced, there is nothing like it, I imagine, to 
be feared from it now, as it is weakened, become old, and its force 
almost quite spent." Another explanation advanced by some writers 
is, that the syphilitic virus retains its power, but that a preservative 
influence is transmitted to posterity by those who have the disease, 
which, like some vegetables, gradually exhausts the soil from which 
it springs of the materials necessary to its support. 

There are other considerations relative to the syphilitic virus, as, 
for instance, the circumstances under which contagion takes place, 
both in the primary and constitutional forms of the disease, which 
will naturally come before us when treating of chancres and 
secondary syphilis. 

Constitutional Syphilis rarely occurs more than once in 
the same person. — It will now be evident that the analogy which 
was drawn at the commencement of the present chapter between 
syphilis and other contagious diseases is exclusively applicable, ex- 
cept so far as relates to the presence of a virus, to the infecting 
chancre and the constitutional disease of which it is the initiatory 
symptom. The second point of resemblance referred to was the 
" immunity which one attack generally confers against a second." 

1 English translation of Astruc, London, 1754, p. 102. 



CONSTITUTIONAL SYPHILIS. 349 

It is true of all diseases which are both contagions and constitu- 
tional, that a person who has once had them is indisposed to con- 
tract them again. Smallpox, scarlet fever, measles, the hooping 
cough, and vaccine disease, all follow this law; and in the rare ex- 
ceptions which sometimes occur, the symptoms are generally so 
modified as still to evince the protecting influence of the first attack. 
The applicability of this law to syphilis was first announced by 
Eicord in 1839, and, in spite of frequent denials, may now be 
regarded as unquestionable. Some explanation is desirable of what 
was called by its discoverer the "unicity" of syphilis. 

Soft chancres, like gonorrhoea, favus, and the itch, are contagious, 
but not constitutional diseases, and one attack confers no immunity 
against a second. Setting aside for the present the phenomena of 
syphilization, which, as we shall see hereafter, may be explained on 
other grounds, a person may contract a soft chancre any number 
of times. It is also compatible with the law of "unicity," that the 
true syphilitic virus should be capable of producing a chancre upon 
a system previously infected ; although, in most cases, as shown by 
artificial inoculation, when the virus is implanted beneath the epi- 
dermis, no effect whatever takes place. Yet, sometimes, inoculation 
succeeds ; and instances are also met with in practice in which a 
person already infected presents a chancre derived from a primary 
ulcer of the infecting type ; but in nearly all such cases, the sore 
fails to present the usual features of a hard chancre ; it is destitute 
of induration, unaccompanied by an indurated bubo, and, above all, 
has no effect upon the general system. In a similar manner, the 
vaccine virus sometimes occasions an imperfectly developed, or 
"false" pustule, upon a system already thoroughly protected against 
vaccinia. 

The immunity, therefore, which is said to be conferred by one 
attack of syphilis, relates only to the constitutional disease, includ- 
ing the hard chancre in its full development. Yet many cases 
occur in practice which are apparent exceptions to this law. After 
contracting an infecting chancre, but few persons escape with only 
one outbreak of constitutional symptoms ; however thorough their 
treatment may have been, one or more relapses usually occur, and if 
one of these has been preceded by a newly caught chancre, the second- 
ary symptoms which follow are frequently ascribed to its influence, 
especially if the second chancre happened to be situated upon the 
remaining induration of the first, and thus simulated the complete 



350 INTRODUCTORY REMARKS. 

infecting nicer. Fortunately, we are able in most instances to re- 
cognize a recent attack of constitutional syphilis by the following 
signs, and in their absence to ascribe the symptoms to an old infec- 
tion : — 

1. By the induration of the preceding chancre and neighboring 
lymphatic ganglia. 

2. By the time elapsing between the appearance of the suspicious 
ulcer and that of the constitutional symptoms ; the interval, in the 
absence of general treatment, and when the latter are dependent 
upon the former, being very uniformly about six weeks, and rarely 
exceeding three months. 

3. By the character of the symptoms, whether belonging to an 
early or late stage of constitutional syphilis. 

4. In some cases, by the influence of treatment; the early symp- 
toms of constitutional syphilis yielding most readily to mercury ; 
the later to iodide of potassium. 

If attention be paid to these circumstances, it is found that excep- 
tions to the immunity conferred by one attack of syphilis are very 
rare, and their existence in any case is by many called in question. 
But I am inclined to think that the " unicity" of the syphilitic virus 
is not so universal as has sometimes been asserted. Not a few 
cases have been reported as exceptions to the law, 1 which have been 
severely, and sometimes, I think, unfairly criticized; nor can I 
regard the explanation of Diday 2 as satisfactory, who, while main- 
taining that the law is always true, still admits "constitutional 
syphilis in two fasciculi" ("verole en deux livraisons comple- 
mentaires"); by which he means that one mild attack of syphilis 
may only partially exhaust the susceptibility of the system, and a 
second attack accomplish what the first left undone. M. Diday 
endeavors to show by a recital of cases, that in these instances of 
double infection, the constitutional symptoms of each are the coun- 
terpart of those of the other; that if, for example, in the first attack, 
the skin was chiefly affected, the most prominent symptoms in the 
second will be seated upon the mucous membranes ; that if febrile 
symptoms ushered in the eruption in the former, they will be ab- 
sent in the latter, etc.; so that to this surgeon the "unicity of 

1 Folltn, Revue Critique, Arch. Gen. de Med., Jan. 1856, p. 86. Gamberini, 
Gaz. Med. de Paris, 21 e annee, p. 1. Rodet, Gaz. Med. de Lyon, 1857, p. 212. 

2 Nouvelles Doctrines sur la Syphilis, Paris, 1858, p. 345. 



CONSTITUTIONAL SYPHILIS. 351 

syphilis" signifies, not that syphilis never affects the same person 
twice, bnt that it " never affects the same person twice in the same 
manner." This explanation, although ingenious, can be regarded 
as little more than begging the question. 

For my own part, I cannot regard this law as absolute, though it 
is doubtless more nearly so than in kindred contagious diseases, as 
variola, vaccinia, etc. I believe it to be true as a general rule, but 
that, in rare instances, two attacks are possible, as in the affections 
just alluded to. Eicord, who first announced the general truth of 
this law, has always stated that he believed exceptions possible and 
was anxious to admit them, since they would show that the syphi- 
litic diathesis did not necessarily last as long as the life of the indi- 
vidual; but up to the time of the publication of his last work, in 
1858, he had met with none which were satisfactory. 1 Eecent 
French journals, however, report the following case, which is said 
to have carried conviction to the minds of Ricord, Puche, and Cul- 
lerier, and in which, it will be observed, Diday's theory is at fault, 
since the symptoms were nearly identical in the two attacks. 

Case. The patient, a brush-maker, 45 years of age, entered the Hopital 
du Midi, in 1838, with an induration remaining after the cicatrization of 
a chancre; red spots upon the chest, abdomen, and internal surface of 
each arm; and mucous patches upon the cicatrix and the scrotum. 
Record's diagnosis, as noted in the hospital record, was: "Chancre; 
syphilis." Under the administration of the protiodide of mercury, the 
symptoms disappeared. 

The patient had a suspicious connection in the month of June, 1859; 
three weeks after a chancre appeared on the integument of the penis, and 
in two or three days two others, one on the skin in the neighborhood of 
the first, the other on the site of the old cicatrix in the groove behind 
the corona glandis. The first chancre was not seen, but the other two 
presented all the characteristics of indurated chancres; the glands in each 
groin, and in the post-cervical region, were also indurated. No local 
treatment was prescribed, and the patient was directed to appear at the 
consultation at the hospital once a week for further observation. Two 
months after the appearance of the chancres, rose-colored papulaa ap- 
peared on the abdomen; a week afterwards, the chest, arms, and belly 
were covered with a papulo-lenticular syphilitic eruption ; scabs were 
found in the hairy scalp, and mucous patches on the uvula. All these 

1 Lecons sur le Chancre, p. 159. 



352 INTRODUCTORY REMARKS. 

symptoms disappeared in three weeks under the administration of the 
protiodide of mercury. 1 

The doctrine we have been discussing has its practical as well 
as theoretical bearings. 

1. Its all but universal truth shows that, as a general rule, one 
attack of constitutional syphilis leaves its impress upon the system 
for life, in the same manner that the vaccine virus does ; and that 
any attempt to eradicate the diathesis by medication would proba- 
bly be as fruitless in one case as in the other. The syphilitic 
" disposition," as Hunter called it, being once formed, the power of 
mercury is limited to retarding, preventing, and suppressing its 
"action," but "it does not destroy the disposition." 2 The cure of 
constitutional syphilis, if by that term is meant the restoration of 
the patient to his original condition, is impossible ; though we may 
still hope to prevent by treatment any farther activity of the latent 
poison. If this can be accomplished, Eicord suggests that the 
patient will be left as after variola, simply protected from future 
attacks. 

2. The exceptional cases of double constitutional syphilis show 
that, in a few fortunate instances, the diathesis becomes very much 
weakened or dies out in time. 

3. If a man who was once known to have constitutional syphilis 
contracts a fresh chancre, there is but little danger of a second 
infection of the system ; and even those who believe in the necessity 
of specific treatment on the first appearance of a primary sore, 
may consistently abstain from employing mercury. Diday relates 
an instance in which he permitted a patient to marry immediately 
after the cicatrization of an ulcer suspected of being an infecting 
chancre, on the ground that he had formerly had constitutional 
syphilis and was not likely to have it again. No evil consequences 
ensued. In another case reported by this author, a man who had 
been very dissipated in his youth married and became the father 
of several cachectic children, whom the family physician, knowing 

1 Gazette Hebdomadaire, 27 Janv. 1860, from tlie Moniteur des Sciences, 14 Janv. 
1860. [Since the above was written, the second edition of Ricord's Lecons sur le 
Chancre has appeared, in which the author acknowledges having met with two 
instances in which constitutional syphilis was contracted twice by the same per- 
son.] 

2 Ricord's Notes to Hunter, 2d ed., p. 417. It would be well if we could also 
say with Hunter that " mercury hinders a disposition from forming, or, in other 
words, prevents contamination." 



CONSTITUTIONAL SYPHILIS. 353 

the man's antecedents, suspected of being affected with hereditary- 
syphilis, and was preparing to treat them with a course of mercury. 
At this juncture, the father contracted an indurated chancre, followed 
by fully developed constitutional syphilis, and his children, no sus- 
picion being attached to the mother, were exempted from specific 
treatment, in the belief that if the father had now become infected 
he could not have been infected before. 1 It may not appear that 
sufficient caution was exercised in these cases considering the risk 
at stake, but they will serve to show the assistance to be derived 
from the law of " unicity" in some difficult cases of diagnosis. 

The two remaining points of analogy between syphilis and other 
infectious diseases, viz., the period of incubation, and the regular 
order in the appearance of the symptoms, will more properly be 
considered in the chapter introductory to constitutional syphilis. I 
would also request the reader's attention to some remarks in the 
chapter on chancres relative to the question whether the infecting 
species is preceded by incubation. If this be admitted, there are 
two periods of incubation of the virus; one between the act of 
contagion and the appearance of the chancre, another between the 
latter and the outbreak of general symptoms. 

Independently of the points of resemblance traced in this analogy, 
syphilis possesses certain characteristics peculiar to itself, and which 
are found in no other contagious disease. No other affection to 
which man is liable so powerfully modifies the constitution for the 
remainder of life, nor exercises so great an influence upon posterity. 
In man as well as the lower animals, peculiarities of structure and 
of character are transmitted from parents to their offspring ; but 
what acquired disease other than syphilis can be conveyed by the 
sperm to the ovum, and through it contaminate the mother and her 
children by another father ? 

The classification and nomenclature of syphilis, as we have 
received them from preceding generations, are extremely faulty, 
and require complete revision. Syphilis is commonly divided into 
" primary," and " constitutional" or " general." Primary syphilis 
is made to include all chancres, whether simple or infecting, and 
buboes. Constitutional syphilis comprises the general symptoms 
which follow infection of the system, and which are separated from 
the primary by a period of incubation. 

1 Nouvelles Doctrines sur la Syphilis, p. 350. 

23 



354 INTRODUCTORY REMARKS. 

General symptoms are subdivided into secondary and tertiary. 
The term " consecutive," which is applied by some authors to gen- 
eral symptoms, is used by Eicord to denote a subdivision of the 
primary, and is made to include those lesions which immediately 
succeed the first developed chancre, and which are similar to it in 
character, viz., chancres which spring up in the neighborhood from 
subsequent inoculation, and buboes. 

It is evident that this classification does not distinguish between 
the simple, and the infecting chancre and its consequences ; and is 
thus attended with great confusion — not to say, absurdity. For 
instance, we may well call the infecting chancre "primary," because 
it is the first symptom which appears after contagion, and, after a 
period of incubation, is followed by lesions which may be called 
secondary. But why give the name of " primary" to the chancroid, 
which is not the first of a series, and which has no secondary? 

Again, the term "primary" is commonly used as synonymous 
with local syphilis; and this is implied by the name of "constitu- 
tional" being given to the next division. But an indurated chancre 
is a primary symptom, and yet induration is undoubtedly an effect 
of general infection of the system. To avoid this difficulty, Mai- 
sonneuve and Montannier have endeavored to make a distinction 
between the sore itself and its induration, by classifying the former 
among primary and the latter among secondary symptoms; and 
they would thus make a secondary symptom coexist with a primary 
and be separated from all other secondary symptoms by a period of 
incubation ! 

I shall in the next chapter adduce proof to show that the infecting 
chancre from the earliest period of its existence is not a local but 
a constitutional lesion. When using the term primary, therefore, 
as applied to the first period of true syphilis, I shall by no means 
intend to imply that any symptom included in that division is a 
local affection. With this explanation the term may be retained, 
since its application to the indurated chancre and its accompanying 
indurated bubo, which are separated from other consequences of 
infection by an interval of incubation, is most appropriate. 

I would also remark that, in accordance with custom, I shall 
sometimes employ the term constitutional as synonymous with 
general symptoms, but without meaning to assert that these are 
the only results of infection of the system. 



CHANCRES. 355 



CHAPTER II. 

CHANCRES. 

A " chancroid" is the local and contagious nicer, which, being 
most frequently transmitted in sexual intercourse, chiefly affects 
the genital organs. 

A " chancre" is the initiatory lesion of acquired syphilis, arising at 
the point at which the virus enters the system, and separated from 
the general manifestations of constitutional infection by a period of 
incubation. It has been generally supposed that the virus of a 
chancre could alone give rise to a chancre ; recent investigations, 
however, appear to show that the conditions of the above definition 
are fulfilled, whatever may have been the source of the virus, 
whether derived from a primary or secondary lesion. 

In common parlance, both the chancroid and the true syphilitic 
sore are included under the name of " chancre." 

I propose, in the first place, to consider the two together in 
respect to their situation, the circumstances under which contagion 
takes place, and the forms which they assume, and afterwards to 
describe each in detail. 

Seat of Chancres. — Chancres are most frequently seated in the 
neighborhood of the genital organs, simply because these parts are 
most exposed to contagion and not in consequence of any peculiar 
aptitude which they possess. If the chancrous virus be inserted 
beneath the epidermis of any other part of the body a chancre is 
equally the result. ISTor is this the limit to the seat of primary 
sores : they are also found within the various mucous canals — as 
the urethra, vagina, rectum, and buccal and nasal cavities — opening 
upon the surface, at as great a depth as these passages can be ex- 
plored by the senses during life; and post-mortem examinations 
have proved the possibility of their presence in the bladder, though 
such instances are extremely rare. The whole external integument, 



356 CHANCEES. 

and whatever portions of the mucous membranes are accessible to 
the implantation of the virus, are therefore exposed to become the 
seat of chancres. The frequency with which they are met elsewhere 
than upon the genitals, depends in a great measure upon the habits 
and cleanliness of persons exposed to contagion. 

Among the situations in which chancres have been observed, but 
where they may readily pass unnoticed, are the following: the 
margin of the anus and cavity of the rectum ; the vaginal walls, os 
uteri, and cervical cavity ; within the urethra and bladder ; under 
the nails of the fingers and toes ; upon the breasts ; on the hairy 
scalp and conjunctiva oculi ; upon the lips, internal surface of the 
cheeks, and the mucous membrane of the fauces and pharynx. 
The following table exhibits the seat of 814 chancres, comprising 
all that were observed at the Hopital du Midi, in the year 185 6. l 

Indurated. Simple. 

Chancres on the glans and prepuce 314 296 

" on the skin of the penis ...... 60 15 

" on various parts of the penis ..... 11 17 

" involving the meatus ...... 32 9 

" within the urethra (not visible on forced separation 
of the lips of the meatus, but recognized by in- 
oculation, palpation, inflammation of the lym- 
phatics, etc/) ....... 17 3 

" on the scrotum and peno-scrotal angle ... 11 

" of the anus ........ 6 2 

" " lips 12 

" " tongue 3 

" " nose ........ 1 

" " pituitary membrane 1 

" " fingers 1 1 

" leg . 1 

To the statement above made relative to the extent of the possi- 
ble seat of chancres, there is an important exception, viz., that the 
non-infecting primary nicer is rarely, if ever, met with upon the 
head or face. By whom this fact was first noticed, is not known, 
but it began to attract attention while the duality of the chancrous 
virus was under discussion, and was used as a strong argument 
against the new doctrine by those who maintained the unity of 
syphilis. " If there are two species of chancre," it was said, " both 
should be met with indiscriminately upon all parts of the body ; 
but all chancres upon the lips, tongue, face, and head, are indurated 



Fournier, Legons sur le Chancre, p. 252. 



SEAT OF CHANCRES. 357 

— none are simple ; does not this prove that induration is depend- 
ent upon the seat of the sore, and not upon the nature of the 
virus ?" The important bearing of this question led to an exten- 
sive investigation for the purpose of ascertaining if the alleged 
exemption was founded on fact. Fournier 1 took a prominent part 
in this labor, and, from a diligent search through medical works 
and inquiry of those who made a special study of venereal, was 
able to collect 150 cases of primary sores upon the head and face, 
all of which, however, with the exception of 5, were hard chancres. 
These five exceptional cases, in which the ulcer was supposed to be 
a chancroid, were observed by MM. Eicord, Yenot, Devergie, Bas- 
sereau, and Diclay ; but Eicord confessed that his case, a chancre at 
the base of one of the superior incisor teeth (figured in his Icono- 
graphie, pi. 21), was unreliable, and the other four were all imper- 
fectly reported ; and thus there could remain no doubt of the rarity, 
if not of the entire absence, of the soft chancre upon the region in 
question. 

This discovery led to considerable speculation, and various theo- 
ries were offered in explanation, of which the one advanced by MM. 
Diday and Fournier was perhaps the most probable, viz., that the 
absence of the soft chancre upon the head and face is due to local 
idiosyncrasy, similar to that which leads many other diseases to 
select certain regions, and avoid others of the same anatomical 
structure. Thus, gonorrhoea, croup, and rheumatism, attack respec- 
tively the eye, larynx, and pericardium, and spare the nose, oeso- 
phagus, and peritoneum ; and scabies is never met with upon the 
face. Fournier was also able in several instances to trace out the 
origin of hard chancres upon the head and face, and found that there 
was never an interchange of the two species, but that they invaria- 
bly arose from hard chancres ; hence, admitting the absence of the 
chancroid upon this region in clinical experience it constitutes no 
argument against the duality of the chancrous virus. 

It has been since ascertained that the chancroid can be developed 
upon the head and face by artificial inoculation. Puche 2 and Eol- 
let 3 have inoculated its virus with success upon different parts of 

1 Etude sur le Chancre Cephalique, Union Medicale, Feb. and March, 1858. 

2 Nadau des Islets, De l'lnoculation du Chancre moil a la Region Cephalique, 
These de Paris, 1858. 

3 Gaz. Med. de Lyon, Dec. 1857. 



358 CHANCEES. 

the head in 20 instances ; Bassereau 1 and Prof. Huebbenet, 2 of Kieff ; 
upon the lips and cheeks in five, and in all the sore so produced 
was entirely free from induration and was not followed by second- 
ary symptoms. The ease with which the chancroid was developed 
does not favor the idea of local inaptitude, and it may be necessary 
to seek for another explanation of the great preponderance of the 
hard chancre upon the cephalic region. Such may readily be 
found if we suppose, with Kollet, that it originates in many cases 
in a secondary lesion, which, as is now believed, communicates 
a chancre by contagion. Contact is no less frequent and intimate 
between mouth and mouth than between the genital organs of the 
two sexes, and the former region is almost as peculiarly the seat of 
secondary manifestations as the latter are of primary. 

I shall content myself with this brief sketch of the discussion 
relative to the "cephalic chancre," which for a time attracted no 
little attention, but which assumes less importance now that it is 
known not to conflict with the duality of the chancrous virus. Its 
only practical bearing is this : that the rarity, if not the entire ab- 
sence of the chancroid upon the head and face, furnishes strong 
ground of belief that any primary sore met with upon this region 
is of the infecting species, and may, therefore, assist in forming a 
diagnosis. 

Contagion. — Simple contact of the syphilitic virus with a raw sur- 
face is sufficient to give rise to a chancre. The most favorable condi- 
tion for contagion to take place is the presence of abrasions or other 
solutions of continuity, such as are frequently occasioned by violence 
during coitus, and through which the poison may penetrate beneath 
the epidermis or epithelium. The application of virulent matter to 
the sound external integument hardened by exposure and friction, 
is as innocuous as the deposit of vaccine virus upon the skin without 
previous puncture. The surgeon frequently soils his fingers with 
the secretion of chancres, and this with impunity so long as their 
surface is intact, but if abraded in the slightest degree, he is liable 
to contract a primary sore. Numerous instances of this accident 
are recorded, and one has occurred within my own circle of acquaint- 
ance, in which a young surgeon thus became infected with consti- 
tutional syphilis. 

Cullerier's experiments relative to mediate contagion establish 

1 Buzexet, Du Chancre de la Bouche, These de Paris, 1858, p. 41. 

2 L'Union Medicale, May 20, 1858. 



CONTAGION. 359 

the fact that virulent pus may be retained for some time in the 
vagina without effect upon the delicate mucous membrane lining its 
walls. As a general rule, however, mucous surfaces offer a much 
less effectual barrier to contagion than the external integument, 
and are, therefore, most frequently the seat of chancres. Even 
when no solution of continuity has prepared the way, the virus de- 
posited in some fold of the membrane or in an open follicle, may 
act as an irritant, produce a superficial erosion, and thus gain en- 
trance beneath the surface. The greater or less time occupied by 
this process will account in a measure for the variable period after 
exposure at which chancres appear, though in the case of the infect- 
ing chancre there are other and more important influences bearing 
upon this point which will be considered hereafter. 

It would appear that the virus of the chancroid when applied to 
the human tissues takes effect more readily than that of the syphi- 
litic chancre. The pus of the soft chancre may be inoculated with 
almost absolute certainty of success, if the operation be properly 
performed. On the contrary, inoculation of the secretion of a hard 
chancre sometimes fails even in the most expert hands and upon 
subjects free from syphilitic taint. According to Fournier, 1 M. Puche 
was unsuccessful in three attempts to implant the indurated chancre 
upon healthy individuals, and Eicord and Ouvry in a fourth. Four- 
nier adds that instances of escape from contagion after exposure are 
not uncommon with the infecting, but are rare with the simple chan- 
cre ; and that most of the reported cases of mediate contagion belong 
to the former species. 

The chancrous virus, like the poison of gonorrhoea employed in 
inoculations for the relief of pannus, retains its power of contagion 
for a considerable length of time. Eicord states that he has inocu- 
lated it with success after preserving it in glass tubes hermetically 
sealed for seventeen days. Sperino relates a remarkable instance of 
the preservation of the virulent properties of the chancroidal virus. 
A lancet which had been employed in artificial inoculation had been 
laid aside for seven months, when it was observed that a small quan- 
tity of dried pus had been left upon its point. The instrument was 
moistened, and three punctures made_with it gave rise to as many 
soft chancres. 

The transfer of matter necessary to contagion most frequently 

1 De la Contagion Syphilitique, Paris, 1860, p. 10b'. 



360 CHANCRES. 

takes place during coitus, but may be accomplished through, the 
intervention of almost any agent, as the fingers, household utensils 
in common use, etc. I have recently seen an infecting chancre upon 
the upper eyelid of a boy whose father had a similar sore, and who 
probably was infected by using the same towel. Eeliable cases are 
reported in which a pipe, tumbler, pen, or pencil was the vehicle of 
transport. Such instances are perfectly in accordance with the phe- 
nomena of contagion in other infectious diseases, and cannot be 
ignored, although they should not induce a blind confidence in all 
the statements of patients, who often wish to escape the responsibility 
of their own acts. Much tact and judgment on the part of the sur- 
geon are often requisite to arrive at the truth. 

It sometimes happens that the origin of a chancre is clearly trace- 
able to a man or woman who is found, on the most careful exami- 
nation, to be entirely well. A man, for instance, has connection with 
a woman of the town who has cohabited with several men within a 
short time, and contracts a chancre ; the woman is submitted to a 
speculum examination, and her genital organs, to their utmost visi- 
ble recesses, are found to be intact. Again, a husband visits a 
prostitute, and, returning home, has intercourse with his wife, who 
becomes infected while he escapes. The observation of facts like 
these led the earlier surgeons after the appearance of syphilis, to 
believe in the possibility of " mediate contagion," or the transport 
of virulent pus from one person to another by the genital organs of 
a third, which merely serve as a vehicle and are not themselves 
inoculated; and this supposition, which has often been rejected as 
fanciful by modern authors, has been proved to be not only possible 
but highly probable by some interesting experiments of M. Culle- 
rier, one of which is reported as follows: — 

Louise Yaudet entered the Lourcine Hospital Oct. 10, 1848, to be 
treated for an ulcer of a grayish aspect and with sharply cut edges in 
each groin, which had already persisted without treatment for a month. 
There was considerable surrounding inflammation, which was subdued by 
rest and poultices, when the genital organs and anus were carefully ex- 
amined and found to be free from ulceration. The vagina was reddened 
and smeared with an abundant muco-purulent secretion, but its mucous 
surface was intact and the os uteri healthy. The inguinal ulcers were 
dressed with charpie moistened in aromatic wine, and vaginal injections 
of a solution of alum ordered ; under which treatment the sores and 
vaginitis rapidly improved. 



FORM OF CHANCRES. 361 

Nov. 25, after finding on a second examination that the mucous mem- 
brane of the vulva and vagina was, as before, intact, and after inoculating 
without success the vaginal secretion, M. Cullerier collected upon a 
spatula a considerable quantity of pus from the chancres in the groins and 
deposited it in the vagina. The patient was then directed to walk about 
under surveillance lest she should touch the parts, and at the end of thirty- 
five minutes was again placed upon the bed, and some of the fluid found 
in the vagina was inoculated upon her thigh. The vagina and vulva were 
then freely washed with water, dried, and washed a second time with a 
solution of alum. Two days after, the inoculation had produced the char- 
acteristic pustule of a chancre, which was left another twenty-four hours 
to confirm the diagnosis and then destroyed with Vienna paste. Repeated 
subsequent examination showed that no ulceration had been caused in the 
vagina, which was not even more inflamed than before. In two months 
the patient left the hospital cured of both her vaginitis and inguinal ulcers. 

In a second case in which this experiment was performed, the 
pus was allowed to remain in the vagina for nearly an hour and did 
not take effect. 1 

Form of Chancres. — When we recollect that the essential difference 
between a chancre and any other sore is the presence in the former 
of a virus which has never been made manifest to the senses — that 
contagious pus inoculates the whole of any solution of continuity, 
whatever its form, which has opened a door of entrance into the 
economy — that chancres like other ulcers are exposed to the com- 
mon causes of irritation and extension, as friction, the stagnation 
and concretion of matter, etc., we cannot be surprised that primary 
sores do not always present the same external aspect; indeed, we 
may rather be astonished that they are ever recognizable except by 
their power of contagion. 

Again, if we examine the symptoms which have commonly been 
received as characteristic of a chancre, we find that they may nearly 
all be produced by non-specific causes; that they therefore owe 
their diagnostic value simply to their greater frequency in primary 
sores; and that they may be present to a greater or less degree in 
ulcers other than those which secrete a specific virus. Take for 
instance the simple chancre ; its circular outline is but the effect of 
ulceration advancing with equal rapidity in all directions from a 
common centre when the sore is situated upon homogeneous tissues ; 

1 Quelques Points de la Contagion mediate. Memoires de la Soc. de Chir., 
quoted in Leqons sur le Chancre, p. 255. 



362 CHANCRES. 

if the seat of the chancre include structures of different density, as 
the prepuce and glans penis, the rounded form is lost; its sharply 
cut edges and grayish floor are also results of the same progressive 
ulcerative action inducing superficial gangrene of the submucous 
cellular tissue ; its areola is only the hyperemia of the surrounding 
capillary vessels. Again, the plastic inflammation which charac- 
terizes the infecting chancre tends to limit the ulcerative process, 
to diminish the depth of the sore, give it sloping edges, and ap- 
proximate the appearance of its surface to the normal color of the 
tissues upon which it is situated; if subjected to irritation, how- 
ever, it extends in surface and in depth, its edges become more 
sharply defined, its floor covered with a grayish secretion, and its 
general aspect approximates to that of a soft chancre. In fact, the 
induration surrounding and underlying the infecting chancre is the 
only feature to be found in the two species of primary sore, which, 
in its well defined outline, cartilaginous hardness and persistency, 
differs from the ordinary effect of common inflammation. 

I do not wish by these remarks to underrate the objective symp- 
toms of chancres, nor to deny that, in the great majority of cases, 
they are sufficient to indicate the nature of the ulcer; but the ten- 
dency has undoubtedly been to regard certain characters, which are 
not constant, as essential, and hence have arisen many errors of 
diagnosis. For example, the classic chancre or chancre-type, was 
for years described as a rounded ulcer, with sharply cut edges and 
a grayish aspect; whereas it is now known that the form of primary 
sore which is most frequently followed by constitutional syphilis, is 
not an ulcer at all, but a superficial erosion, which has unquestion- 
ably, in numerous instances, been overlooked in consequence of 
implicit faith in certain symptoms which this variety does not 
possess. 

The inconstancy of chancres is not so great, however, but that 
they may nearly all be included under the following forms, viz : 
1. Superficial erosions; 2. Pustules; 3. Simple ulcers; 4. Phage- 
denic ulcers ; 5. Gangrenous ulcers. Both the simple and infecting 
chancre may assume either of these forms, but each has its favorite. 

The superficial erosion is almost exclusively confined to the in- 
fecting chancre. It does not involve the whole thickness of the 
skin or mucous membrane, and heals without leaving a cicatrix. 

A pustule is always observed after successful inoculation of the 
chancroid, when the inoculated point is protected from abrasion ; if 



ARTIFICIAL INOCULATION. 363 

left unbroken, it is soon covered by a dark scab under which the 
pus burrows and extends ; if ruptured, the following form is found 
beneath it. 

The simple excavated ulcer belongs especially to the simple chancre, 
but is not unfrequently assumed by the infecting primary sore, par- 
ticularly when subjected to irritation. It involves the whole thick- 
ness of the skin or mucous membrane, and, on healing, leaves a 
cicatrix behind. 

Phagedenic ulcers are much more frequently simple than infect- 
ing chancres. The ulcerative action varies greatly in different cases, 
and thus occasions wide differences in the aspect of the sore. 

Gangrene may attack either species of chancre in consequence of 
excessive inflammation of the neighboring tissues. A dark-colored 
eschar is formed, and when this is detached the chancre is generally 
found to be transformed into a simple ulcer, as after the application 
of a powerful caustic. 

With the exception of some phagedenic chancres, all primary 
ulcers will sooner or later heal spontaneously. Either with or 
without treatment, they gradually lose the characteristics of a spe- 
cific sore, and, before cicatrization takes place, their power of con- 
tagion ; in short, they are transformed from specific into simple 
ulcers. The existence of a chancre has, therefore, been divided into 
two periods : the first including the time during which the ulcer — 
still progressing or stationary — secretes contagious pus ; the second 
the final stage during which its secretion is innocuous. The divid- 
ing line between these two periods cannot always be determined 
with accuracy; it is, however, important to recollect that in the 
latter portion of the existence of a chancre inoculation is no longer 
of value as an assistance to diagnosis. 

Artificial Inoculation. — To artificial inoculation, which was first 
employed to any great extent by Eicord, we are indebted for much 
of the progress which has been made in our knowledge of syphilis 
since the commencement of the present century ; and I make this 
statement fully aware of the fact that this valuable means of inves- 
tigation has sometimes led into error, and that its application is 
much more limited than it was supposed to be before the recent dis- 
covery that infecting chancres, like the secretions of constitutional 
syphilis, cannot be inoculated upon the person bearing them. 

In performing artificial inoculation, some convenient part of the 
integument, as the arm, thigh, or abdomen, is selected, and a super- 



364: CHANCRES. 

ficial puncture made beneath, the epidermis, as in inoculating the vac- 
cine virus. The lancet employed should be new, or freshly ground, 
and little, if any, blood should be drawn, lest it wash away the 
virus, and invalidate the experiment ; if more appear than is barely 
sufficient to redden the part, a fresh puncture should be made. 
Some of the secretion which, it is desired to test should now be in- 
serted in the wound, and the inoculated point covered with a watch- 
glass to protect it from abrasion. The glass is retained in place by 
strips of adhesive plaster arranged around its margin, and leaving 
the centre free through which the effect may be observed. If the 
inoculation be successful, the point of puncture becomes red in the 
course of a few hours ; by the second or third day, it has swollen, 
and forms a small papule, surrounded by a reddish areola ; on the 
third or fourth day, the epidermis is raised by an effusion of serum 
which soon becomes turbid from an admixture of pus ; by the fifth 
day the fluid is decidedly purulent, and forms a pustule, the sum- 
mit of which is often umbilicated like the pustule of variola ; mean- 
while, the surrounding areola has been increasing in width, and 
depth of color, and has now attained its height. The pustule thus 
formed is often termed the " characteristic pustule" of a successful 
inoculation, and is identical in appearance with the pustule of ec- 
thyma ; if any doubt remain as to its nature, its secretion may be 
tested by a second inoculation. If the pustule be left unbroken, 
the contained matter concretes, and forms a scab of a conical form, 
which increases by additions to its circumference. If this scab be 
removed, an ulcer is found beneath it, which has been regarded as 
the type of a chancre. Its peculiarities are, that it penetrates the 
whole thickness of the skin or mucous membrane, so that its floor 
is formed by the subjacent cellular tissue ; its edges are abrupt, 
jagged, and often slightly undermined ; its outline is circular ; its 
surface is of a grayish color, and uneven, presenting slight eleva- 
tions and depressions which are best seen through a magnifying 
glass. The tendency of this ulcer is to extend, or, at least, not to 
diminish, for weeks ; and in this it again differs from the pustule 
and more superficial ulceration, which may be induced by the ino- 
culation of simple but irritant matter. 

Such is the evolution of a chancre after artificial inoculation, as 
observed by Ricord and others, in many thousand instances. From 
the immediateness with which the morbid process uniformly fol- 
lowed the insertion of the virus, Ricord was led to deny that a 



ARTIFICIAL INOCULATION. 365 

chancre has any period of incubation, and to explain the reported 
cases of its tardy appearance, on the supposition that it had passed 
for some time unnoticed. This and other inferences from experi- 
mental inoculation have, however, been invalidated, so far as they 
have been applied to both species of chancre indiscriminately, by 
the discovery that the secretion of a hard chancre is not inoculable 
upon the individual bearing it, or upon any person whose system is 
already under the influence of constitutional syphilis. Singular as 
it may appear that this fact was never known before, its truth is 
fully established by the recent experiments of numerous observers. 
But Eicord's inoculations were always performed upon the pa- 
tient's own person, and never upon healthy individuals ; hence, the 
virus employed when the result was positive must necessarily have 
been, with rare exceptions, that of a soft chancre, and the con- 
clusions which were drawn can only be admitted as true of this 
species of primary sore. To obtain an equal amount of informa- 
tion relative to the evolution of infecting chancres, would require 
a repetition of these experiments with the virus of true syphilis 
upon persons free from syphilitic taint, but such a course, so inevi- 
tably detrimental to the constitution for life, cannot be justified, and 
has never been attempted, except in a few instances, by Wallace, 
Waller, Yidal, Kinecker, and some others. We shall presently see 
that clinical observation teaches the existence of a period of incu- 
bation for infecting chancres, which is wanting in the chancroid. 
A consideration of these facts also leads to the conclusion that the 
unsuccessful inoculation, upon a person already infected, of the 
secretion of any sore, is no proof of its simple nature ; and hence 
that the value of this test in the diagnosis of primary ulcers has 
been greatly exaggerated, since it fails in those very instances in 
which it is most important that it should be reliable. "Auto- 
inoculation" — as it has sometimes been called — can only be em- 
ployed to indicate the presence or absence of the chancroidal virus. 
Artificial inoculation of the secretion of a chancre upon the 
person bearing it does not increase the danger of constitutional 
infection, which is never dependent upon the number or extent of 
the ulcerations. It has, however, been known to develope phage- 
denic ulcers of an exceedingly troublesome character and which 
were a long time in healing. I have myself seen two cases ; one in 
the New York Hospital, in which artificial inoculation, performed 
before the patient's entrance, had given rise to an extensive ulcer 



366 CHANCRES. 

upon the thigh of several years' duration; and another in the 
Pennsylvania Hospital, Philadelphia. Other cases are reported in 
works on venereal. With due caution, however, this accident may 
be avoided, and artificial inoculation be employed with safety for 
the purposes to which it is applicable. So soon as the pustule is 
developed — on the third or fourth day after inoculation — it should 
be destroyed by a strong caustic, as Vienna paste or nitric acid ; if 
cauterization be deferred till the fifth or sixth day, the neighboring 
tissues may have become so infiltrated with the virus that the 
most thorough application will fail to include them all and to 
transform the specific into a simple ulcer. 



CLASSIFICATION" OF CHANCRES. 

The only radical distinction between chancres sufficient to con- 
stitute distinct species is that existing between the simple and 
infecting chancres ; there are, however, several sub-varieties. Both 
kinds of chancrous virus may be present in the same sore, which is 
then denominated a " mixed chancre ;" and either species of chancre 
may be attacked by violent inflammation terminating in gangrene, 
or by phagedena; whence arise "gangrenous" and "phagedenic 
chancres." We have therefore to consider : — 

1. The simple chancre. 

2. The infecting chancre. 

3. The mixed chancre. 

4. The gangrenous chancre. 

5. The phagedenic chancre. 

Comparative Frequency of the Simple and Infecting Chancre. — 
Simple chancres constitute by far the larger proportion of primary 
ulcers. Of 341 chancres observed at the Hopital du Midi in the 
course of three months, 126 were infecting and 215 simple. M. 
Puche has prepared a table of all the primary sores under treat- 
ment at the same hospital during ten years (1840 — 1850), forming 
a total of 10,000 chancres, of which 1955 were infecting and 8045 
were simple j 1 in other words, the ratio of the former to the latter 
was nearly as 1 to 4. The statistics of other observers vary some- 
what from the above, but they all concur in showing the greater 
frequency of the soft chancre. Eicord explains this difference on 

1 Fodknier, Lemons sur le Chancre, p. 15. 



SIMPLE CHANCRE. 367 

two grounds: first, that the chancroid furnishes a more copious 
secretion, and generally for a longer period, than the chancre ; and, 
secondly, that an attack of the former, unlike one of the latter, 
affords no protection against subsequent contagion. The greater 
difficulty also of inoculating the infecting ulcer is probably not 
without influence. 

Simple Chancre. — This species of primary sore is also known 
as the "chancroid," "soft chancre," "non-infecting chancre/' and 
" contagious ulcer." 

The phenomena following artificial inoculation as above de- 
scribed, exhibit the mode of evolution of the soft chancre and the 
various forms it may assume. It is not preceded by a period of 
incubation. The ulcerative process commences immediately upon 
implantation of the virus, and is sufficiently advanced to attract 
the notice of the patient in from two to eight days after contagion. 
The late period at which a few soft chancres are observed is to be 
ascribed to the contagious matter having remained for some time 
upon the surface before penetrating beneath the epidermis or epi- 
thelium, or else to the sore having been overlooked. 

When the part inoculated is the internal surface of a follicle or 
fissure, the mouth or edges of which close over the imprisoned virus, 
the resulting chancroid first appears as a pustule or small abscess, 
which remains intact for a longer or shorter period, according as it 
is protected, or not, from abrasion. The pustular form of chancre 
is, however, not common, except as the result of artificial inocula- 
tion — or, rather, the pustule is usually ruptured before the patient 
comes under observation, and only the ulcer beneath it remains. 
When contagious matter has inoculated a previous solution of con- 
tinuity, the chancroid is from the outset an open sore, at first corre- 
sponding in shape and size to the fissure, rent, or abrasion, in which 
it is developed, and gradually assuming the more marked characters 
of a specific ulcer. 

The soft chancre, when fully formed, presents the following 
symptoms : its outline is circular, unless modified by the shape of 
the solution of continuity in which it is implanted ; by a differ- 
ence in the density of the tissues beneath it, as when seated upon 
the margin of the glans penis and prepuce, when it extends most 
rapidly in whatever direction the tissues are most lax ; or, by the 
union of several adjacent chancroids, when the resultant ulcer 



368 CHANCRES. 

may be very irregular. Chancroids upon the free margin of the 
prepuce appear like slits or fissures, while the glans is covered, but 
when the latter is exposed, are found to be nearly circular. 

The rapid perforation of the skin or mucous surface by the 
chancroid, appearing as if a portion of the membrane had been 
punched out, is highly characteristic of this species of primary sore. 
The edges are jagged, abrupt, and sharply cut, and do not adhere 
closely to the subjacent tissues. The floor of the ulcer is uneven, 
studded with minute elevations, " worm eaten," and covered with 
a pseudo-membranous secretion of a grayish-yellow color, which 
cannot be removed without violence. The fluid secretion is copious 
and purulent ; under the microscope it is found to consist of pus- 
globules mixed with organic detritus. 

The simple chancre is surrounded by an areola which varies in 
width and depth of color with the degree of attendant inflammation. 
The condition of the tissues around and beneath the chancroid is 
one of the most important elements of diagnosis between this and 
the infecting chancre. In the form we are now considering, the 
parts always preserve their normal softness and suppleness, unless 
subjected to some irritant, or attacked b}^ simple inflammation. 
Inflammatory engorgement, however, is not well defined like the 
specific induration of the infecting chancre, but gradually subsides 
into the normal suppleness of the neighboring tissues, to which it 
is adherent ; it is also less firm, and of a more doughy feel, and dis- 
appears shortly after the cessation of the inflammation which occa- 
sioned it. The application of any astringent lotion, or caustic, as 
nitrate of silver, potassa fusa, nitric acid, etc., may cause hardness 
which so closely resembles specific induration, that it cannot be 
distinguished from it, except by its shorter duration ; and, for the 
time being, the diagnosis must be founded upon other symptoms. 
Still another source of error is the possibility of a chancroid being 
situated upon the persistent induration of a previous infecting 
ulcer. 

Simple chancres are more frequently multiple than single. Of 
254 patients in the Hopital du Midi, 48 bore one, and 206 several 
simple chancres ; and of the latter, 116 had from three to six ; 41 
from six to ten ; 8 from ten to fifteen ; 4 from fifteen to twenty ; and 
5 over twenty. 1 Of 118 patients in the Antiquaille Hospital at 

1 Fournier, op. cit., p. 41. 



INFECTING CHANCRE. 369 

Lyons, affected with soft chancres, 50 presented one, and 68 several. 1 
When but one chancroid appears at the outset as the immediate 
result of contagion, others are apt to spring up around it from suc- 
cessive inoculation, since the original ulcer pours out an abundant 
secretion, and its presence confers no immunity against others. 

A simple chancre is very persistent. Unless it can be destroyed 
by a strong caustic or otherwise, it will generally last for weeks or 
months, however skilfully it may be treated either by local or con- 
stitutional remedies. Fournier has shown that it may be inoculated 
upon the person bearing it up to the time when cicatrization is 
nearly complete : as Eicord expresses it, the specific period of the 
chancroid absorbs nearly the whole of its existence. During the 
reparative period, a simple chancre sometimes fills up with granu- 
lations to a level with the surrounding surface and simulates a 
mucous patch or tubercle, a symptom of constitutional syphilis. 
The absence of other general symptoms and the condition of the 
neighboring ganglia are generally sufficient to establish the diag- 
nosis ; or the sore may be tested by inoculation. If it be a soft 
chancre, it can be inoculated upon the person bearing it, but not if 
it be a true mucous patch. 

An examination of the neighboring lymphatic ganglia affords 
assistance of the highest value in distinguishing the two species of 
chancre, for the details of which the reader is referred to the chapter 
upon buboes. The soft chancre may or may not affect the condition 
of these ganglia. Of 267 cases of chancroid observed at the Hopital 
du Midi in one year, Qo were attended with bubo, and 142 were 
not. 2 Of 140 patients in the service of M. Eollet at Lyons, 52 were 
free from inguinal reaction, while 83 had buboes of which 60 were 
virulent. 3 The affection of the lymphatic ganglia attendant upon 
the simple chancre is limited to but one of these bodies, is always 
inflammatory, and tends to suppuration ; and this alone of the two 
species of chancre can give rise to a suppurating bubo the pus of 
which is inoculable. 

Infecting Chancre. — This species of primary sore, from its 
exclusive right to the appellation, is called "the chancre;" some- 
times also the "true," "hard," "indurated," and "Hunterian" chancre, 
or " primary syphilitic ulcer." 

1 Debadge, Traitement des Chancres Simples, etc., These de Paris, 1858, p. 6. 

2 Fournier, op. cit., p. 34. 3 Debauge, op. cit., p. 72. 

24 



370 CHANCEES. 

Has the infecting chancre a period of incubation ? This is an 
important question, since it involves two others of great practical 
interest : 1. Whether the true chancre is a local or constitutional 
lesion. 2. Whether its abortive treatment can prevent systemic 
infection. The solution of this question by experimentation is 
impracticable, since inoculation of the hard chancre upon persons 
already infected is impossible, and upon healthy individuals un- 
justifiable. We can, therefore, refer only to clinical observation, 
and, even here, no slight difficulty is encountered. Patients may 
not come under observation until some days or weeks after con- 
tagion ; they have often had sexual connection repeatedly at short 
intervals ; and their statements as to the time of infection and the 
appearance of the chancre are not aLways reliable. But many 
careful observers have noticed the fact that, as a general rule, 
advice is sought at a later period for infecting chancres than for the 
chancroid, and the interval between contagion and the appearance 
of the ulcer is represented by patients as longer in the former than 
in the latter. Thus Diday made minute inquiry of twenty -nine 
persons whose chancres were of recent origin ; who appeared to be 
trustworthy, and certain of the facts which they stated ; who had 
been exposed but once, and who had had no previous connection 
for at least a month, and found that the average interval between 
the sexual act and the appearance of the sore was fourteen days. 1 
M. Chabalier, in an examination of ninety cases of infecting chancre, 
found an average period of incubation of from fifteen to eighteen 
days ; and states that the chancroid, on the contrary, is visible 
within thirty-six or forty-eight hours after contagion. 2 M. Clerc 
has especially insisted upon the presence or absence of incubation 
as diagnostic of the two species of primary sore, and has reported 
several cases of infecting chancre which were preceded by a period 
of incubation of thirty days. I have myself met with a number of 
cases in which the interval between a single exposure and the 
appearance of an infecting chancre exceeded ten days, and in one 
there is every reason to believe that it was of much longer duration. 
A gentleman of this city, of high social position, whom I know so 
intimately that I can vouch for the truth of his statements, visited 
Paris unaccompanied by his wife, and, while under the influence of 
wine, for the first time during fifteen years of married life, had 

1 Gaz. Med. de Lyon, March 1, 1858. 

2 These de Paris, No. 52, 1860, p. 111. 



INFECTING CHANCRE. 371 

connection with, a woman of the tOAvn. This was on the eve of his 
return to America, and his subsequent remorse and anxiety were 
so great that on his voyage home he examined himself daily with 
the greatest care to see if he had contracted any disease. His pre- 
puce was very short, so that the glans was habitually uncovered and 
no lesion was likely to escape observation, yet he found nothing 
until the day of his arrival home, the thirty-fifth after exposure, 
when he noticed a slight excoriation upon the internal surface of 
the prepuce. He showed it to his family physician, a Homoeopath, 
who told him that it was a mere abrasion which would heal in a 
few days, and that he might with safety have connection with his 
wife. As the promised cicatrization did not take place, on the 
fourth day after his arrival he applied to me, and I found a super- 
ficial chancre with well-marked parchment induration and attendant 
indurated ganglia. Since then he has had several attacks of con- 
stitutional syphilis, and his wife, who was in the fifth month of 
pregnancy, contracted an indurated chancre, had a syphilitic erup- 
tion, alopecia, iritis, etc., and gave birth to an infected child at 
term, which, under homoeopathic treatment, died at the age of one 
month. 

While writing these pages, my advice has been sought by a 
very intelligent physician, who was exposed but once to contagion 
on the night of August 16, and a well-marked indurated chancre 
which he now bears upon the internal surface of the prepuce first 
appeared, September 1 ; making an interval of sixteen clays. I 
have also at the present time under my care a merchant, who has 
been subject to herpes, and has been in the habit of watching his 
genital organs very closely after exposure. He now has an infect- 
ing chancre, which he is positive did not show itself until five weeks 
after his last coitus. 

Castelnau reports a case communicated to him by the physician 
of a venereal hospital, who was himself the subject of the observa- 
tion, in which an infecting chancre appeared thirty -three days after 
an impure intercourse. 1 

But we have still more conclusive evidence of the incubation of 
the hard chancre in three cases in which the inoculated point was 
watched from day to day. The first is reported by Eollet. This 
surgeon, desirous of testing the character of a sore, inoculated its 

1 Annales des Maladies de la Peau et de la Syphilis, t. i. p. 212. 



372 CHANCRES. 

secretion without success upon the person bearing it. He then 
repeated the inoculation upon several persons who were affected 
with constitutional syphilis, and with the same negative result. 
This was previous to the' discovery of the fact that the infecting 
chancre is not auto-inoculable ; hence Eollet believed it safe to 
inoculate the secretion of the same sore upon still another indi- 
vidual, who was free from true syphilis, although affected with 
simple chancres and a suppurating bubo. The inoculation proved 
successful and gave rise to an infecting chancre, which did not 
make its appearance until the eighteenth day. 1 In two other cases 
of artificial inoculation of the infecting chancre, one performed by 
Einecker and the other by Gibert, the period of incubation was 25 
and 24 days respectively. 

When speaking of the abortive treatment of chancres, I shall also 
adduce facts to show that destructive cauterization of an infecting 
chancre, at a very early period of its existence, does not prevent 
secondary symptoms, and hence that the system must be regarded 
as infected from the first. Moreover, the analogy of other infectious 
diseases, as vaccinia, glanders, etc., leads us to infer that the absorp- 
tion of the syphilitic virus is instantaneous. Farther observation 
is required fully to determine why the infecting chancre sometimes 
appears at an early, and at other times at a late period ; although 
it is probably due to accidental differences in the conditions under 
which contagion takes place ; the virus being implanted in a wound 
which in some cases continues patent and in others closes until 
constitutional reaction is felt. 

The following table, prepared by M. Bassereau, 2 of the chancres 
which preceded 170 cases of syphilitic erythema, will indicate the 
various forms which an infecting chancre may assume, and afford 
some idea of their comparative frequency in the milder cases of 
the constitutional disease, of which the more severe instances are 
preceded by a larger proportion of excavated ulcers : — 3 

Superficial erosions ........... 146 

Circumscribed ulcers, with abrupt edges, involving the whole thickness of 
the skin or mucous membrane ......... 14 

Circumscribed phagedenic ulcers, with a pultaceous floor, involving the 
tissues a short distance beyond the skin or mucous membrane . . 10 

Total 170 



1 Archives Gen. de Med., Avril, 1859, p. 409. 

2 Op. cit., p. 140. 3 See section on Phagedenic Chancres. 



INFECTING CHANCKE. 373 

It appears from this table that the infecting chancre has no 
exclusive form, but that it most frequently assumes one which 
differs widely from the chancre-type as heretofore described by 
most authors. The frequency of the superficial form of infecting 
chancre excited my attention several years before I had met with 
any description of it in books, and the first cases which came under 
my notice were mistaken for mere abrasions until the appearance 
of secondary symptoms corrected the diagnosis. Within the last 
year, a physician, well instructed in the literature of venereal, 
applied to me with a superficial chancre so closely resembling a 
simple abrasion that I could not persuade him of its specific cha- 
racter, and therefore advised him to examine the woman with whom 
he had had connection and see if she did not present symptoms of 
syphilis. A few weeks after, they both called at my office; the 
physician, with syphilitic erythema; his mistress, with syphilitic 
papulae. 

The superficial form of infecting chancre is most marked on the 
internal surface of the prepuce, by which it is protected from the 
air and friction, and kept free from scabs ; and it is in this situation 
that I have most frequently met with it. It has generally a circular 
or ovoid, but sometimes irregular, outline. Its floor is but slightly, 
if at all, excavated, and occasionally is even elevated above the 
surrounding integument by the subjacent induration. Its surface 
is smooth, often looking as if polished, destitute of the consistent 
and adherent exudation of the chancroid, and of a red or grayish 
color. Its secretion is a clear serum — free from pus-globules, unless 
the sore has been irritated — which may often be seen issuing from 
minute pores, after the previous moisture has been wiped away. 
It has no surrounding areola, and leaves no cicatrix to mark its 
site. Barely one-third of the chancres in Bassereau's 170 cases, left 
any visible trace aside from induration. When situated upon the 
external integument, as the sheath of the penis — where most chan- 
cres are of the infecting species — and exposed to the air, it becomes 
covered with scabs, which give it the appearance of a pustule of 
ecthyma, or a patch of scaly eruption, and which may readily lead 
to an error in diagnosis. The characters of the chancrous erosion 
are also modified by the application of irritants, or by a want of 
cleanliness ; its secretion may become purulent, and its surface re- 
semble that of the chancroid ; but its normal appearance may be 
restored by applying a water- dressing for a few days. 



374 CHANCRES. 

Frequent as is the chancrous erosion, it must not be regarded as 
the exclusive form of the infecting chancre. I am inclined to think 
it more common among patients of the better class who observe 
habits of cleanliness, and whose favorable hygienic condition is not 
conducive to ulceration. Between this form and the indurated ex- 
cavated ulcer, known as the Hunterian chancre — which was so long 
and so erroneously supposed to be the especial harbinger of con- 
stitutional syphilis — there may exist many gradations which it is 
unnecessary to describe in detail. Ulcerative action may, though 
rarely, go beyond this point, and terminate in phagedena; but, 
generally, it is limited by the plastic inflammation of the surround- 
ing tissues, as is evident from an examination of the edges of nearly 
all the forms of infecting chancre, which are sloping, somewhat pro- 
minent, and adherent, unlike the abrupt and detached margins of 
the chancroid. 

A pustular form of the infecting chancre is certainly rare in prac- 
tice, and its occurrence after artificial inoculation, owing to the small 
number of successful results, doubtful. It would appear, at least 
in most instances, that the papule which is first developed does not 
become a pustule, but takes on superficial ulceration. Mr. Henry 
Lee believes that this is invariably the case, and that a pustule, the 
result of artificial inoculation, is diagnostic of the chancroid. 1 In 
performing inoculation with the virus of the hard chancre, the 
lengthy incubation of this species of sore should not be forgotten, 
nor the result be pronounced negative, until after the lapse of a 
month or six weeks. 

We have yet to consider those characters which are common to 
all the forms of infecting chancre. 

Induration was recognized at a very early period in the history 
of syphilis by John de Vigo, 2 Gabriel Fallopius, 3 Leonard Botal, 4 
and Ambrose Pare, 5 as a prominent symptom of the chancre which 

» British and Foreign Med.-Chir. Rev., Oct. 1856. 

2 "Nam ejus origo in partibus genitalibus, videlicet in vulva in mulieribus et 
in virga in hominibus, semper fuit cum pustulis parvis, interdum lividi coloris, 
aliquando nigri, non nunquam subalbidi, cum callositate eas circumdante." (John 
de Vigo, Practica copiosa in Arte Chirurgica, etc. Rome, 1514, lib. v.) 

3 Tractatus de Morbo Gallico, Patavium, 1564. 

4 Luis Venerese curandse ratio, Paris, 1563. 

5 " S'il y a ulcere a la verge et s'il demeure durete au lieu, telle chose infaillible- 
ment montre le malade avoir la vairole." (Pare's works, first published at Paris, 
1575, Book 19th.) 



INFECTING CHANCRE. 375 

precedes constitutional syphilis; nearly forgotten by subsequent 
writers, though occasionally mentioned, as by Nicholas Blegny, 1 it 
has again assumed importance in modern times from the teachings 
of Hunter, 2 Bell, 3 and especially Eicord, and is now justly regarded 
as the most characteristic feature of the infecting chancre, when 
seated upon a person exempt from previous syphilitic taint. 

The induration of a chancre is a peculiar hardness of the tissues 
around and beneath the sore. Simple inflammation may occasion 
an effusion of plastic material and consequent engorgement about 
any sore ; but specific induration is of an entirely distinct character. 
The latter is formed, as the French say, "a froid," that is, without 
inflammatory action ; the deposit takes place in the absence of all 
the symptoms of inflammation, "pain, heat, redness, and swelling;" 
and so silently, so insidiously, that the patient is often ignorant of 
its presence, or discovers it only by accident. No event is more 
common than for a surgeon to be consulted by a man who states 
that he had a sore a few weeks ago, "which did not amount to 
much;" he "burnt it with caustic and it healed up;" but he has 
recently found that it left a "lump" behind it. This "lump" is 
specific induration and denotes that the constitution is infected. A 
gentleman recently applied to me for phymosis — neither congenital 
nor inflammatory — which occasioned no inconvenience except an 
inability to retract the prepuce. He was not aware that he had had 
any venereal trouble, but, on examination of the parts, a mass of 
induration as large as an almond was perceptible to the touch and 
almost to the sight — so great were its dimensions — situated about 
the furrow at the base of the glans. The phymosis was simply due 
to the mechanical obstruction presented by the induration to the 
retraction of the prepuce, and this difficulty alone induced him to 
seek advice. Frequently, also, patients apply to a surgeon for treat- 
ment for constitutional syphilis, and honestly declare that they have 
never had a chancre, though the previous existence of such, and 
even its very site, are unmistakably indicated by the remaining in- 
duration. 

Again, specific induration and inflammatory engorgement differ 
in their objective symptoms. The boundaries of the former are 
clearly defined, while the extent of the latter cannot be limited with 

1 L'Art de Guerir les Maladies Veneriennes, etc., Paris, 1673. 

2 Ricord and Hunter on Venereal, 2d Am. edition, Phil. 1859, p. 286. 

3 Treatise on Gonorrhoea Virulenta and Lues Venerea, London, 1793, vol. ii. p. 19. 



376 CHANCRES. 

nicety ; the one terminates abruptly, the other shades gradually into 
the normal suppleness of the part ; the first is freely movable upon, 
the second adherent to, the tissues beneath. The difference in the 
sensations they impart to the fingers is still greater ; specific indu- 
ration is so firm, hard, and resistent, that it is often compared to a 
"split-pea" 1 or mass of cartilage; the softer and doughy feel of 
common inflammatory engorgement requires no description. It is 
hardly necessary to say that there is no incompatibility between 
these two pathological conditions which can prevent their co-exist- 
ence, and hence arises, in some few cases, a difficulty of diagnosis. 
The effect of simple inflammation, however, subsides in a few days, 
or in a week or two at farthest, and lays bare the specific indura- 
tion, which may, for a time, have been buried beneath it ; and under 
all circumstances reference may be made to the neighboring ganglia, 
the induration of which is equally constant and significative with 
that of the chancre. 

In the masses of induration of considerable size to which the above 
description chiefly refers, the adventitious deposit occupies the skin 
or mucous membrane bordering upon the edges of the sore, and 
also the cellular tissue beneath it. There is another, but less com- 
mon form of induration, in which the deposit is confined to the 
mucous membrane alone, and does not involve the cellular tissue 
beneath. It most frequently occurs in connection with the super- 
ficial chancre, and is called the "parchment-induration" because it 
imparts to the fingers a sensation as if the erosion rested upon a 
thin layer of that material. Eeadily perceived in most cases, in 
others it may escape notice, especially to one not familiar with it. 

The situation of the chancre influences to a certain extent the 
degree of development of the induration ; which, for instance, is 
generally but slightly marked and of the parchment variety upon 
the walls of the vagina and the margin of the anus ; while, on the 
contrary, it is fully developed in the furrow at the base of the glans 
and upon the lips. Some authorities have gone so far as to maintain 
that induration is entirely dependent upon the seat of the sore, and 
have instanced the uniformity with which all chancres upon the 

1 Benjamin Bell usually has the credit of the comparison of induration to a 
split-pea, but reference to his work shows that he uses the term as indicative of 
the size of a chancre, and not of the consistency of its base. He says : " A real 
venereal chancre is seldom so large as the base of a split-pea, and the edges of the 
sore are elevated, somewhat hard, and painful." Op. cit., vol. i. p. 19. 



INFECTING CHANCRE. 377 

•lips are indurated in proof; but, as before stated in this chapter, 
this objection to the duality of the chancrous virus has been effectu- 
ally exploded by recent experimental inoculations, in which chan- 
cres with a perfectly soft base have been developed upon the region 
in question. 

Eicord believes that the development of induration corresponds 
with the supply of lymphatic vessels; that the former is most 
marked where the latter are most abundant ; and that the indura- 
tion, in fact, consists in an inflammation of the capillary absorbents 
with effusion into the intervening tissue. 1 The tendency of indura- 
tion to invade the lymphatic system favors this opinion, which, 
however, has not been corroborated, to my knowledge, by the 
necessary anatomical investigations. Those microscopists 2 who have 
examined the histology of induration concur in stating that it is 
composed of fibro-plastic elements — fusiform bodies, nucleated cells, 
free nuclei, and amorphous matter — infiltrating the layers of the 
derma and subcutaneous tissue, without any special characters to 
distinguish it from similar products of non-specific origin. These 
elements are not found in the secretion of the sore. 

Eicord, to whose careful investigations I am indebted for a large 
part of the present section, has endeavored to determine the limits 
of time within which induration may take place. He states that it 
occurs most frequently during the first or second week after con- 
tagion ; never before the third day, nor after the third week ; that, 
consequently, if a chancre is to be indurated at all, it will be so by 
the twenty-first day after the sexual act in which it originated. It 
is with great reluctance and hesitation that I dissent from so accu- 
rate an observer, but believing as I do in the incubation of the 
infecting chancre, I cannot but think that this subject requires 
renewed investigation with the additional light we now possess. I 
believe it would be nearer the truth to substitute the words " after 
the appearance of the chancre" in place of " after contagion." Taking 
the former as the starting point, there can be no question that in- 
duration occurs within a very few days ; I have almost invariably 
met with it during the first week, and should not hesitate to regard 
its absence, at the termination of three weeks, both in the sore 

1 Lecons sur le Chancre, p. 86. 

2 Robin et Marchal de Calvi, Elements caracteristiques du tissu fibro-plastique 
et sur la presence de ce tissu dans l'induration du chancre. Seance de l'Academie 
des Sciences, Nov. 2, 1846. Lebekt, Traite d'Anatomie Pathologique, vol. ii. 



378 CHANCRES. 

itself and in the neighboring ganglia, as indicative that the patient 
was safe from constitutional infection. 

Sigmund, 1 of Vienna, gives the following table of the dates after 
contagion at which induration was first detected in 261 infecting 
chancres. 

On the 9th day in 71 cases. 

" 10th " 84 

" 14th " 76 

" 17th " 15 

" 19th " 12 

" 21st " 3 

Mr. Babington, the English editor of Hunter on Venereal, ad- 
vanced an opinion which has been adopted by a few authors, that 
induration may take place before the appearance of the chancre ; 
but experience does not confirm this statement. After all, if it be 
admitted that all possible mischief is accomplished long before the 
chancre first appears, the exact date of the evolution of the indu- 
ration possesses less practical importance than it assumed under 
the supposition that it marked the boundary line between local and 
constitutional syphilis. 

Specific induration usually remains for a long time after the 
cicatrization of the chancre, and, unless dissipated by treatment, 
may, in most cases, be felt for at least two or three months, and 
often longer. Some statistics collected by M. Puche show that its 
persistency becomes rarer after the third month, and is quite excep- 
tional after the eighth, though this surgeon reports thirteen cases 
in which it was perceptible from 390 to 2062 days after contagion ; 
in nine of the thirteen, the induration occupied the furrow at the 
base of the glans, a favorite seat for its full development and long 
persistency. M. Puche met with still another instance in which 
induration persisted for nine years. I have met with several cases 
of two and three years' duration, and Ricord with one of thirty 
years. It follows from the above data that induration is an early 
symptom of constitutional syphilis, and that the time within which 
its presence or absence is of diagnostic value is limited, though 
variable in different cases. 

Induration is sometimes much shorter lived ; the parchment form 
especially, according to Eicord, may entirely disappear before the 

1 British and For. Med.-Chir. Rev., Jan. 1857, p. 206 ; from the Wien Wochen- 

schrift, No. 18. 



INFECTING CHANCRE. 379 

chancre heals, and the cicatrix present as soft a base as the chan- 
croid. This form of induration is, however, in many instances, as 
durable as any other. 

As the process of absorption goes on, the indurated mass becomes 
less firm and resistent, and gradually softens until it can finally no 
longer be detected. Occasionally a relapse takes place in which it 
resumes its original characters. I have seen such accompany a 
renewed outbreak of a syphilitic eruption ; while, in other instances, 
the exciting cause has appeared to be some local irritation, as a soft 
chancre, vegetation, etc. 

Unlike the chancroid, the chancre is rarely met with in groups 
of two or more upon the same subject. Of 456 patients, under the 
observation of Fournier at the Hopital du Midi, 226 had but one 
and 115 several chancres ; of the latter 86 had two, 20 had three, 5 
had four, 2 had five, 1 had six, and 1 had nineteen. Debauge col- 
lected 60 cases at the Antiquaille Hospital, at Lyons, in 41 of 
which there was a single chancre, and in 19 several. 1 These statis- 
tics would show that the infecting chancre is solitary in three cases 
to one in which it is multiple. The ratio is still greater in M. 
Clerc's observations, in which the chancre was single in 224 out of 
267 cases. If multiple at all, infecting chancres are so as the imme- 
diate effect of contagion, and because several rents or abrasions were 
inoculated together in the sexual act. If solitary at first, they con- 
tinue to be so ; since successive chancres never spring up in the 
neighborhood, as in the case of the chancroid, owing to the fact 
that the virus ceases to act upon the system as soon as it is once 
infected. This explanation is alone sufficient, without calling in 
the aid, as Kicord does, of the paucity of the secretion, which is 
copious enough to inoculate sound persons. 

The insidious manner in which induration takes place character- 
izes the whole development of the infecting chancre, and it is not 
surprising that it often exists for some time before it is perceived 
by the patient, or escapes notice entirely. The explanation of many 
"buboes d'emblee" and supposed cases of constitutional syphilis 
without chancre is evident. Unfortunately the profession has been 
too prone to go to extremes in taking the testimony of venereal 
patients: by some their statements are received implicitly; by 
others they are as constantly disbelieved ; while few draw the dis- 

1 Op. cit., p. 6. 



380 CHANCRES. 

tinction between honesty, and ignorance necessarily arising from 
want of experience and the absence of medical knowledge. 

The secretion from an infecting chancre is much less copious 
than that from the chancroid. This difference is especially evident 
in the superficial erosion, but is also perceptible in the excavated 
forms, the discharge from which is less free and purulent than in 
the simple chancre. 

Numerous experiments show that the immunity conferred by one 
attack of constitutional syphilis extends in most cases, and perhaps 
in all, even to the initiatory sore. Fournier inoculated the dis- 
charge of ninety-nine hard chancres upon the patients themselves, 
and succeeded in but one, in whom the experiment was performed 
within a very short period after contagion. M. Puche states as the 
result of his own experiments that auto-inoculation of the infecting 
chancre is successful in only two per cent. Poisson obtained like 
results in fifty-two cases, 1 and Laroyenne was unsuccessful in every 
one of nineteen. 2 Do not these facts tend to show that the hard 
chancre is from the very first a constitutional lesion ? Their bear- 
ing upon the use of artificial inoculation as a means of diagnosis is 
evident; failure favoring the supposition that the sore is an in- 
fecting chancre. The great rarity of successful inoculations of 
the hard chancre strongly favors a supposition recently advanced, 
that such exceptional cases are really mixed chancres and not 
uncomplicated infecting ulcers ; if this be so, auto-inoculability may 
be regarded as belonging exclusively to the chancroid and mixed 
chancre. 

It should be observed that Mr. Henry Lee, of London, as early 
as 1856, and prior to the publication of the French experiments, 
called attention to the difficulty of inoculating indurated chancres, 
or " syphilitic sores affected with specific adhesive inflammation," 
upon the persons bearing them. 3 This surgeon has since maintained 
that if an indurated chancre — the discharge from which, under 
ordinary circumstances, he believes to be destitute of pus-globules 
— be irritated, as by the application of a blister or ung. sabinae, 
until its secretion becomes purulent, it is susceptible of inoculation. 4 
Mr. Lee's experiments require confirmation before coming to any 

1 Lecons sur le Chancre, p. 274. 

2 Annuaire de la Syphilis, annee 1858, p. 241. 

3 British and For. Med.-Chir. Rev., Oct. 1856. 

4 Ibid, for April, 1859. 



INFECTING CHANCEE. 381 

conclusion regarding them. It is difficult to believe that in the 
numerous French observations the sores had always escaped irrita- 
tion and that the discharge was invariably serous. 

The difficulty of inoculating the virus of an infecting chancre is 
equally as great upon a person who has arrived at any stage of 
secondary or tertiary syphilis as upon one who has but recently 
been infected. 

The infecting chancre, as a general rule, is of somewhat shorter 
duration than the chancroid, but often remains until after the 
appearance of secondary symptoms — a remark which I should not 
think it necessary to make had I not met with persons who supposed 
that primary syphilis must terminate before secondary commenced ! 
Of 97 cases observed by Bassereau, in which no treatment had been 
employed, syphilitic erythema, one of the earliest general symptoms, 
occurred in 58 before, in 18 during, and in 21 after the cicatrization 
of the chancre. 1 

Phagedena generally spares the infecting chancre or limits its 
ravages to the destruction of the surrounding induration. In rare 
instances, however, an extensive phagedenic ulcer has been the door 
of entrance of the syphilitic virus into the economy. 

An infecting chancre situated upon the external integument, as 
the sheath of the penis, often leaves a peculiar discoloration of the 
skin of a sombre brown or brownish-red color, which is never seen 
after the chancroid ; in time its dark hue fades into a white. An 
instance of this kind is figured by Eicord in his Iconographie des 
Maladies Veneriennes, pi. 18. 

Eicord first called attention to the fact, which has since been verified 
by many observers, that an infecting chancre during the reparative 
period may be transformed into a mucous patch, and thus a primary 
be changed into a secondary lesion. This transformation may take 
place upon any part of the body whether of skin or mucous mem- 
brane, but is more frequent upon the latter, especially when habitu- 
ally in contact with an opposed surface, whereby heat and moisture 
are maintained ; as, for instance, upon the internal surface of the pre- 
puce and labia major a, and upon the lips and tongue. Davasse and 
Deville have carefully studied the progressive changes by which 
this process is accomplished. 2 The surface of the chancre loses its 

' Op. cit.,p. 180. 

2 Etudes Cliniques des Maladies Veneriennes ; des plaques niuqueuses. Arch. 
Gen. de Med., -le serie, vol. ix. p. 182. 



382 CHANCRES. 

grayish aspect and fills up with florid granulations, commencing at 
the circumference, as in the ordinary period of repair ; but just as 
these changes are reaching the centre of the sore, a narrow white 
border of plastic material appears around its margin, and extending 
towards the centre, finally covers it with the membranous pellicle 
which is characteristic of a mucous patch. If the patient does not 
come under observation until these changes have been effected, the 
origin of his constitutional disease may be ascribed to a mucous 
patch instead of to the chancre to which it belongs. 

"We have already seen that most simple chancres are free from 
ganglionic reaction, and that when this occurs it is always inflamma- 
tory and involves but one ganglion, which tends to suppuration and 
often furnishes inoculable pus. The infecting chancre, on the con- 
trary, gives rise to changes in the neighboring lymphatic ganglia, 
which, by their constancy and the peculiarity of their symptoms, 
are of the highest value in diagnosis. A number of these bodies 
become enlarged and indurated in a similar manner to the base of 
the chancre, without inflammatory action ; they do not suppurate 
except in rare instances, and the pus is never inoculable. The 
induration of the neighboring ganglia, or the indurated bubo at- 
tendant upon an infecting chancre, will be more fully described in 
the next chapter. 

Mixed Chancre — a combination of the soft and hard chancre. — 
"A fact, or an ingenious fiction to obviate the difficulties of a too 
systematic classification?" In reply to this question, no one can 
doubt that a hard and soft chancre may occupy different situations 
upon the same person at the same time. Universal experience de- 
monstrates that constitutional infection presents no barrier to simple 
chancres. The two species of primary sore may, therefore, coexist 
upon the same person. But suppose that in consequence of the 
nearness of their sites, the virus of one comes in contact with the 
other, what will be the effect ? Will either poison be neutralized 
or destroyed, or will each maintain its peculiar properties and the 
resultant sore combine those of both ? The latter supposition, which, 
moreover, does not conflict with any established principles of pa- 
thology, is shown to be correct, both by clinical observation and 
direct experiment. The following case is related by Fournier : — 

Alphonse N., aged 17, contracted a chancre in the latter part of Sept., 
1857. He became an out-patient of the Hopital du Midi, Oct. 3, when 



MIXED CHANCRE. 383 

a chancre, surrounded by cartilaginous induration, was found in the fossa 
behind the corona glandis, and the glands in both groins were enlarged, 
hard, and indolent. A dressing with aromatic wine was ordered for the 
sore, and mercury internally. 

Oct. 14. The chancre has entered upon the period of repair ; it is less 
excavated, and its edges less prominent. 

Oct. 24. There has been a change for the worse. The original chancre 
has increased in surface and in depth ; its base is still very much indurated. 
Moreover, upon the skin of the penis is found another large chancre ; its 
base cedematous, but without true induration. There are also several 
small chancres with soft bases upon the external surface of the prepuce. 
The patient declares most positively that he has had no sexual connection 
since he contracted his first chancre. Are the recent sores to be attributed 
to accidental inoculation from the first ? N. is this day admitted as an 
in-patient. 

In the early part of Nov. one of the lymphatic ganglia in the left groin 
became acutely inflamed, and presented all the characters of a bubo 
dependent upon a simple chancre. It suppurated, and its pus was inocu- 
lated with success. In the right groin, the enlargement and induration of 
the ganglia characteristic of an infecting chancre remained as before. 

In Dec. secondary symptoms appeared : roseola and multiple mucous 
patches. 

In spite of the patient's denial, Ricord attributed the more recent 
chancres to a second exposure and fresh contagion ; and a few days after his 
entrance into the hospital, the patient privately confessed to M. Fournier, 
the Interne, that on Oct. 15th he had connection with a woman whose 
name and address he gave. He also stated that on the following day his 
first chancre began to enlarge, and the others appeared two days after. 

Fournier immediately visited the woman indicated by IS"., and found 
that she had three large chancres with perfectly soft bases, situated upon 
the internal surface of the left labium, on the fourchette and upon the 
folds at the entrance of the vagina, and of about three weeks' duration. 
The inguinal ganglia were in a normal condition. 

This woman also confessed to M. Fournier that she had infected her 
lover, Charles V., who, by a singular coincidence, was at that moment a 
patient in the Hopital du Midi, and who likewise had several simple 
chancres with soft bases upon the prepuce and an acute bubo in the left 
groin. 

To sum up this history : a man with an infecting chancre in the 
period of repair and an indolent indurated bubo has connection 
with a woman affected with simple chancres. He contracts fresh 



384 CHANCRES. 

chancres which are simple, and one of which is seated upon the 
surface of the infecting chancre. An inflammatory bubo appears, 
which suppurates and furnishes inoculable pus. Finally, symptoms 
of constitutional syphilis are developed. 1 
Eollet relates a similar case : — 

G. Francois, aged 20, entered the Antiquaille Hospital, at Lyons, with 
a chancre situated upon the meatus which was slightly indurated and 
presented the usual aspect of an infecting chancre. The fossa at the base 
of the glans was studded with several chancrous ulcers which were as soft 
as possible. The ganglia in the groin were indurated. In six weeks after 
exposure, the patient was attacked with headache, syphilitic roseola, and 
rheumatic pains. 

In order to confirm the diagnosis as to the nature of the sores, Rollet 
inoculated matter from the one which was indurated upon the left thigh, 
and the secretion of the others upon the right. The result was positive 
in both. It was then thought that pus from the simple sores might have 
been deposited upon the indurated one, and thence taken up upon the 
lancet. Rollet therefore waited until the chancres in the fossa behind the 
corona had completely healed, and then, after repeatedly cauterizing the 
indurated sore with solid nitrate of silver, inoculated its secretion a second 
time. This inoculation produced the characteristic pustule of a chancre 
as before ; thereby showing that the success of the first was not owing to 
the presence of matter which had been simply deposited and again taken 
up, but to the inherent properties in the secretion of the sore itself. 3 

M. Rollet and his Interne, M. Laroyenne, were led by this case 
to try the effect of inoculating indurated chancres with matter from 
a chancroid. Their experiments are briefly related as follows : — 

Case 1. Pieri M. ; indurated chancre of the meatus; duration three 
weeks; indurated ganglia; inoculation of the secretion of the chancre, 
negative. Sept. 14, the pus of a simple chancre was deposited upon the 
sore. Sept. 15, application of the solid nitrate of silver; lotions; dress- 
ing with aromatic wine. Sept. 19, second inoculation; chancrous pus- 
tule. 

Case 2. John L. ; indurated ulcer almost healed; indurated ganglia; 
general treatment and local application of aromatic wine; inoculation 

1 Leeons sur le Chancre, p. 119. 

2 Laroyenne, Etudes Experimentales sur le Chancre, Annuaire de la Syphilis, 
annee 1858, p. 248. 



MIXED CHANCRE. 385 

negative. Nov. 18, pus from a simple chancre is applied to the ulcer; 
treatment continued. Nov. 23, second inoculation ; this time positive. 

Case 3. Robert M. ; parchment variety of chancre upon the skin of the 
penis ; duration five days. Dec. 11, inoculation without result ; dress with 
opiated cerate and calomel. Dec. 16, application of the virus of a simple 
chancre. Dec. 17, same dressing. Dec. 22, inoculation positive. 

Case 4. Peter M. ; infecting chancre of six weeks' duration, occupying 
three-fourths of the circumference of the fossa glandis. Dec. 11, inocu- 
lation unsuccessful. Dec. 16, application of the virus of a simple chancre. 
Dec. IT, dress with opiated cerate with addition of calomel. Dec. 22, 
inoculation successful. 

According to Eollet, two or three days after the application of 
the virus of a chancroid to a chancre, the sore assumes a grayish 
aspect like the soft chancre, but is less excavated than the latter ; its 
edges become jagged, and its purulent secretion more copious and 
sanious ; it may give rise to successive chancres in the neighborhood 
or to a virulent bubo. It preserves, however, the essential charac- 
ters of an infecting chancre, and, among others, induration of its 
base, which is always pathognomonic ; the ganglia of both groins 
are indurated as usual, unless a virulent bubo supervenes, when 
those of the opposite side still indicate the nature of the disease. 
The constitutional effects of the true chancre are not modified by this 
inoculation, and secondary symptoms appear at the same time and 
in the same manner asunder ordinary circumstances. The more 
copious secretion of the chancroid renders this species more liable 
to be ingrafted upon the infecting chancre than the latter upon the 
former. 

Thus far we have supposed the inoculation of one species of virus 
to succeed that of the other, but both sometimes, though rarely, 
occur during the same act of coitus. In this case the chancroid, 
which has no period of incubation, is first developed in its usual 
form, with abrupt edges, grayish floor, and soft base ; subsequently 
the infecting chancre appears, when the base of the sore and the 
neighboring lymphatic ganglia become indurated. If, as is probably 
true, those infecting chancres which are auto-inoculable belong to 
the mixed variety, we may obtain some idea of the frequency of 
this form from the inoculations of Eicord, Fournier, Puche, and 
others ; about two per cent, of which have been successful. Eollet's 
observations make the ratio about five per cent. Eollet is inclined 
to believe that the ulcer which has been described by Carmichael, 
25 



386 CHANCRES. 

Kicord, and Eoyer as the " ulcus elevatum," is a mixed chancre, 
which generally shows a tendency to become elevated above the 
surrounding surface. 1 

The union of the two species of virus in this variety of chancre is 
analogous to the mixture which takes place when gonorrhoea is 
complicated with urethral chancre, constituting the only true "gon- 
orrhoea virulenta;" and also to the union of either chancrous virus 
with that of vaccinia, of which a number of examples are recorded. 

Complications of Chancres. — These are chiefly two : excessive in- 
flammation and phagedena. 

Inflammatory or Gangrenous Chancre. — The inflammation 
attendant upon a chancre is sometimes so excessive as to terminate 
in gangrene, and produce a slough of the surrounding tissues, like 
that caused by the application of a powerful caustic. This compli- 
cation is most liable to occur in cases of congenital or accidental 
phymosis, in which the primary sore is imprisoned beneath the 
prepuce. The extremity of the penis is very much swollen and 
cedematous, and often of a livid red color ; a dark spot of commenc- 
ing gangrene soon appears, generally upon the dorsal surface, and 
involves the prepuce to a greater or less extent ; the constricted 
portion, or glans, commonly suffers less than its covering ; if the 
slough include the whole neighborhood of the chancre, the latter, 
when the eschar is detached, presents the appearance of a simple 
wound, and — it is important to recollect — no longer secretes inocu- 
lable pus. The inflammation attendant upon chancres complicated 
with paraphymosis may result in a similar manner. 

It is evident that the excessive inflammation, which is generally 
induced by mechanical constriction, violence, want of cleanliness, 
or the abuse of alcoholic stimulants, is to be regarded merely as a 
complication of the original sore, and does not change its nature, 
whether it be of the simple or infecting species , nor does it affect 
the liability of constitutional infection. The chancroid is more 
exposed to this complication than the infecting chancre. When 
occurring in the latter, induration may for a time disappear with 
the eschar, but often reappears in the subsequent cicatrix, and 
secondary symptoms follow in the usual time and manner. In- 

1 Kollet, De la Plurality des Maladies Veneriennes ; Gaz. Med. de Lyon, No. 7, 

1860. 



PHAGEDENIC CHANCRES. 387 

flammatory or gangrenous chancres are included by most English 
writers among the phagedenic, but there would appear to be suffi- 
cient reason to follow the classification adopted by the French, and 
consider them as distinct. 

Buboes are rare in connection with this variety of chancre. 

Phagedenic Chancres. — In the chancroid and in the infecting 
chancre, when the latter assumes the form of an ulcer, the process 
of ulceration is generally slow and limited in extent, and advances 
with nearly equal rapidity in all directions; whence the sore 
maintains a rounded form, and does not involve the tissues to any 
great extent or depth. Phagedenic chancres, on the contrary, are 
characterized by their more rapid, extensive, and irregular prog- 
ress; though these characters vary greatly in degree in different 
cases. 

In the mildest and most frequent form of phagedena, the sore 
extends in surface and in depth beyond its ordinary bounds ; this is 
sometimes observed at all parts of the circumference, but generally 
at one part more than another, so that the circular form is lost, and 
the outline becomes irregular ; still ulcerative action is not exces- 
sive, and, in the case of the infecting chancre, is often limited to the 
destruction of the induration. 

Phagedena may stop here, or go on to form a serpiginous chancre, 
to the extent and duration of which there is no limit. The edges 
of the sore in this variety are thin, livid, and cedematous, and so 
extensively undermined that they fall upon the ulcerated surface, or 
may be turned back like a flap upon the sound skin ; they are often 
perforated at various points, and are very irregular in their outline, 
resembling a festoon. The surface of the sore is uneven, and co- 
vered with a thick pultaceous and grayish secretion, through which 
florid granulations at times protrude, and bleed copiously upon the 
slightest touch. Serpiginous chancres are not attended by much 
constitutional reaction. They exhibit a predilection for the super- 
ficial cellular tissue, and are inclined to extend in surface rather 
than in depth. They sometimes undermine the whole skin of the 
penis as far as the pubes, or make their way down the thigh nearly 
to the knee, or upwards upon the abdomen, or follow the course of 
the crest of the ilium. They often advance on one side, while they 
are healing upon the opposite. Their progress may appear to be 
arrested, and the sore nearly cicatrized, when rapid ulceration again 



388 CHANCRES. 

sets in and destroys the newly-formed tissue. Their secretion is 
copious, thin and sanious, and preserves its contagious properties 
through the many years that the ulcer may persist. They leave 
behind them a whitish and indelible cicatrix, resembling that pro- 
duced by a deep burn. 

This primary sore may be mistaken for the serpiginous ulceration 
of tertiary syphilis. It is distinguished from it by the fact that it 
commences with a chancre — usually seated upon the genitals — or 
with a suppurating bubo in the groin ; that from this point of origin 
it extends by a continuous process of ulceration, the course of which 
is evident by the foul cicatrix which it leaves behind it; and that 
it never overleaps sound portions of the integument. Moreover, 
the fluidity of its secretion does not favor the formation of scabs, 
and its contagious properties are manifest if inoculated upon the 
person bearing it. 1 

A third variety is called the sloughing phagedenic chancre, and 
is characterized by the greater acuteness of the destructive action. 
Its symptoms closely resemble those of hospital gangrene. There 
is considerable constitutional disturbance, a full and hard pulse, 
furred tongue, and other symptoms of inflammatory fever. The 
pain is often excessive, and almost insupportable. The ulcer ex- 
tends chiefly to dependent parts in the neighborhood, which are 
infiltrated by its copious and foul secretion. It respects no tissue 
whatever, and its ravages are sometimes terrible; the glans, penis, 
•or labia may be wholly destroyed, and the testicles entirely laid 
bare. The sloughing phagedenic chancre is most common among 
the intemperate and lowest class of prostitutes, and also among 
persons visiting hot climates and exposed to various hardships. It 
was this variety which decimated the English troops in the Penin- 
sular war, although syphilis was a comparatively mild disease among 
the natives. 

Phagedenic chancres are not unfrequently attended by buboes, 
which generally take on the same destructive action as the primary 
sore. 

Pournier's confrontations, already referred to, prove that the 
phagedenic chancre is not always transmitted in its kind, and that 
hence it cannot depend upon a distinct species of virus. It does 
not, however, conflict with this statement to admit that contagious 

1 Bassereau, op. cit., p. 475. 



PHAGEDENIC CHANCRES. 389 

matter may possess noxious properties independent of the contained 
virus, but capable of exciting a severe form of ulcerative action. 
This appears not improbable when we consider that vaccine lymph 
which is derived from unhealthy tissues or allowed to stand in 
solution until it becomes putrid, may develop such a degree of 
inflammation as to prove fatal. Witness the mortality in the town 
of Westford, Mass., in the spring of 1860, following vaccination 
with scabs originally pure, but which were dissolved in water and 
exposed to air and heat until they were decomposed. 1 In most 
cases, however, phagedena is doubtless dependent upon some form 
of constitutional cachexia, the exact nature of which is not always 
apparent. The abuse of mercury in the treatment of primary sores 
is another cause, which was more frequent a few years since than 
now ; and the improved practice of the present day may account 
in a measure for the partial disappearance of this variety of chancre. 

Phagedena is a complication common to both species of primary 
sore, but much more frequently of the simple than infecting chan- 
cre;, no certain inference can, therefore, be drawn from its presence 
relative to constitutional symptoms, but merely a probability that 
they will not occur. When they do supervene, they are generally 
of an aggravated character. Babington says : " The secondary 
symptoms which follow the phagedenic sore are peculiarly severe 
and intractable. They commonly consist of rupia, sloughing of the 
throat, ulceration of the nose, severe and obstinate muscular pains, 
and afterwards inflammation of the periosteum and bones. Similar 
complaints will follow the ordinary chancre ; but when they follow 
a phagedenic sore they are very difficult to be cured ; and it is not 
uncommon that the constitution of the patient should at length give 
way under them, and that the case should terminate fatally." 2 

Bassereau also found a correspondence between the severity of 
the primary sore and that of the syphilitic eruption. Thus, of 68 
chancres which preceded a pustular syphilide, 20 were phagedenic 
and 4 others serpiginous; 3 and 18 of 50 chancres followed by a 
tubercular eruption produced destruction of the tissues to a greater 
or less extent. It will be recollected, on the contrary, that 143 of 
170 chancres followed by syphilitic erythema were mere erosions, 
and that 10 only exhibited a very slight tendency to phagedena. 

1 Boston Med. and Surg. Journal, May, 1860. 

2 Ricord and Hunter on Venereal, 2d ed., p. 351. 

3 Op. cit., p. 442. 



390 CHANCKES. 

Bassereau states that a similar relation exists between the primary 
sore and other constitutional lesions, and lays down the rule that 
"mild syphilitic eruptions and ; in general, those constitutional symp- 
toms which exhibit but little tendency to suppurate, follow the mild 
forms of indurated chancre; while pustular eruptions, and, at a 
later period, ulcerative affections of the skin, exostoses terminating 
in suppuration, necroses, and caries, follow phagedenic indurated 
chancres." Admitting the general truth of this rule, it does not 
prove that the phagedenic chancre possesses any peculiar powers 
of infection, but simply that the primary sore may be taken as an 
index of the state of the system, which determines, in a great mea- 
sure, both the severity of the chancre and that of the succeeding 
constitutional symptoms. 

DIAGNOSIS. 

When a sore can be watched through the stages of its evolution 
and decline, it is rare that we are not able to decide whether it 
be a chancre or not; and if so, to what species it belongs. The 
case is quite different when we are called upon to express an 
opinion from a single examination as to the nature of an erosion or 
ulcer, especially if the knowledge of its history be imperfect either 
through the patient's ignorance or deceit; the diagnosis may be 
comparatively easy in most cases, but in many it is difficult, and in 
some impossible. Much will depend upon the time at which the 
sore is seen. The chancroid and especially the infecting chancre, 
when fully developed, present symptoms which are almost unmis- 
takable to one at all conversant with syphilis; but at an earlier 
period, particularly if they occupy a previous solution of con- 
tinuity, no human eye can see and no human means detect, at once 
and without delay, the presence of a specific virus. 

These remarks are not unimportant, since most patients suppose 
that a competent surgeon can "tell a chancre at first sight;" and I 
have known young practitioners make the same mistake and feel 
much chagrined at meeting with cases in which they were at fault. 
To such it may be a consolation to know that experience, though 
doubtless adding very much to the facility of diagnosis, cannot, 
however great it may be, invariably enable the possessor to say 
from a single examination, "such a sore is a chancre," and "such a 
one is not." It is not so many years since I was myself a student 



DIAGNOSIS. 391 

of venereal, that I have forgotten the difficulties in the way of the 
learner, and the embarrassment which is felt in not knowing exactly 
how far diagnosis is possible. On referring to the sections upon 
diagnosis in works upon syphilis, many of them are found to be ob- 
scure, and others diffuse and filled with minutiae which cannot be 
verified in practice ; and the impossibility in any case of arriving at 
a diagnosis is seldom or never hinted at. In short, the student feels 
the want of a few plain and practical rules, such as almost every 
one after a little experience frames for himself in his own mind, and 
upon which he relies to determine the nature of any suspicious sore 
following sexual intercourse. This want I shall endeavor to supply 
to the best of my ability. 

Suppose, in the first place, that a patient makes his appearance a 
day or two after connection with a woman of the town, and exhibits 
one or more raw surfaces upon the penis, which were occasioned by 
violence at the time of coitus. It is clearly impossible at this early 
period to determine whether they have been inoculated with the 
virus either of the chancroid or true syphilis. If they be kept clean 
and protected by the interposition of lint, their nature will be ap- 
parent in a day or two; by which time a simple abrasion will 
generally make some progress towards cicatrization, while a chancre 
will assume the characters of a specific ulcer. 

Again, three or four days after exposure, a man seeks advice for 
one or more small ulcers upon the glans or prepuce, which first 
appeared within twenty-four or forty-eight hours after coitus. Their 
early development does not favor the diagnosis of an infecting 
chancre which possesses a period of incubation. A multiplicity of 
the sores points in the same direction. If not infecting chancres, 
they may be ulcers succeeding herpes- vesicles, or chancroids. The 
former supposition is probable if the patient has been subject to 
herpetic eruptions ; if there are several sores arranged in a circular 
group, some of them, perhaps, still preserving the form of vesicles 
or vesico-pustules ; and if the ulcerations are superficial. The latter 
supposition is the more probable, if the ulcers be irregularly situated, 
and if they perforate the whole thickness of the mucous membrane 
and present the sharply-cut edges and grayish floor of the chancroid. 
The diagnosis may, if thought desirable, be confirmed by inoculat- 
ing the secretion upon the arm or thigh ; if herpes, the result will 
be negative; if a chancroid, positive. Moreover, the former, in 
most cases, rapidly improves or entirely disappears in three or four 



392 CHANCRES, 

days under simple applications alone ; a chancroid grows larger or 
remains stationary, and its characters become more strongly marked. 

Subsequent to the fourth or fifth day the symptoms of both species 
of chancre are generally recognizable without much difficulty ; but 
there are several points which require attention. 

Irritant applications — as, for instance, cauterization by the patient 
himself before seeking advice — may so obscure the symptoms as to 
render a diagnosis impossible until the effect of the application shall 
have subsided. 

Chancres are most liable to be overlooked or mistaken when 
situated at a distance from the genital organs ; the infecting chancre 
less so, perhaps, than the chancroid, owing to the prominent character 
of the induration of the base and neighboring ganglia in the former. 

The superficial form of infecting chancre does not differ materially 
in appearance from a common excoriation, or from the superficial 
ulcerations of balanitis ; it may be distinguished by its late appear- 
ance after exposure, its induration and greater persistency. No 
suspicion of a chancre, however, may be awakened if the erosion be 
surrounded by simple inflammation of the mucous membrane, unless 
the induration of the inguinal ganglia be discovered, and hence the 
condition of these bodies should always be examined in apparent 
cases of balanitis. 

No opportunity should be neglected of examining the person 
from whom the disease was derived. Since there is never an inter- 
change between the chancroid and true syphilis, the symptoms 
presented by the giver of a primary sore will throw light upon the 
nature of the disease in the recipient. The absence of induration, 
the presence of a suppurating bubo, or, provided no general treat- 
ment has been administered, the non-appearance of general symp- 
toms within three months after contagion in the former, will indicate 
that the latter has a simple chancre. On the contrary, if a person 
with an indurated specific ulcer or with constitutional syphilis, 
communicate a sore to another, the latter, without doubt, has an 
infecting chancre. This method of arriving at a diagnosis is of 
special value in married life. In several instances, when informed 
by husbands affected with syphilis that they had communicated 
their disease to their wives, I have been able to treat the latter by 
means of specific remedies without making an examination, and 
have thus avoided a disclosure which could accomplish no possible 
good, and would surely have been productive of much misery. 



DIAGNOSIS. 393 

Inoculation of the secretion of a sore npon the person bearing it 
is an unfailing test of a chancroid, but of no value in infecting 
chancres. 

Induration of the base of a sore and of the neighboring lym- 
phatic ganglia are the two most important symptoms of an infecting 
chancre. Both together are very rarely, if ever, wanting. Of the 
two, I am inclined to regard the latter as most invariably present. 
Absence of induration of the base cannot always be depended upon, 
even according to Eicord's showing, who says that this symptom 
sometimes disappears after a few days' duration, and it may, there- 
fore, have passed away before the patient comes under the care of 
the surgeon. Cases are reported by competent observers of chan- 
cres with a perfectly soft base, which have yet been followed by 
constitutional syphilis ; such instances, however, are extremely rare. 
If a caustic or astringent has recently been applied to a sore, indu- 
ration of its base should be admitted with caution : examine the 
condition of the neighboring ganglia; direct simple applications 
only for a week or two, and see if the hardness persists. In- 
flammation of the surrounding tissues may counterfeit or mask 
specific induration : here, again, refer to the ganglia, or defer the 
diagnosis until the inflammatory products shall have time to undergo 
absorption. 

Even admitting that cases may possibly occur in which indura- 
tion of the base and of the ganglia are both absent, yet these two 
prominent symptoms of an infecting chancre are as constant and as 
valuable as any others in the whole range of pathology : more than 
this we can neither ask nor expect. If it be true that absorption 
of the syphilitic virus takes place instantaneously so soon as it has 
penetrated beneath the epidermis, and that there is, therefore, no 
opportunity of preventing constitutional infection by abortive treat- 
ment, there is less necessity for an early diagnosis than was formerly 
supposed ; and, in obscure cases, we may wait, if necessary, until 
after the time within which, if ever, secondary symptoms invariably 
appear. 

The presence of a mixed chancre is indicated by one or more 
chancroids springing up in the neighborhood of a primary sore 
presenting the usual symptoms of an infecting chancre; also by 
the existence of indurated ganglia in one groin and a suppurating 
bubo in the opposite, especially if the pus be inoculable. In the 
absence of these symptoms (since successive ulceration and sup- 



394 



CHANCRES. 



p-urating buboes do not attend every chancroid), an infecting chancre 
may still be of the mixed variety, and its nature can only be deter- 
mined by artificial inoculation. 



DIAGNOSTIC CHARACTERS OF THE SIMPLE AND INFECTING CHANCRES. 



THE SIMPLE CHANCRE. 

Origin. 
Always derived from a simple chancre, or 

virulent bubo. 

Anatomical characters. 
Generally multiple, either from the first or 

by successive inoculation. 

An excavated ulcer, perforating the whole 
thickness of the skin or mucous membrane. 



Edges abrupt and well-defined, as if cut with 
a punch, not adhering closely to subjacent 
tissues. 

Surface flat but uneven, "worm eaten," 
wholly covered with grayish secretion. 

No induration of base unless caused by 
caustic or other irritant, or by simple in- 
flammation ; in which case the engorge- 
ment is not circumscribed, shades off into 
surrounding tissues, and is of temporary 
duration. 
Pathological tendencies. 

Secretion copious and purulent, inoculable. 



Slow in healing. Often spreads and takes 
on phagedenic action. 

May affect the same person an indefinite 
number of times. 
Characteristic gland affection. 

Ganglionic reaction absent in the majority 
of cases. When present, one gland acutely 
inflamed and generally suppurates. Pus 
often inoculable, producing a soft chancre. 

Prognosis. 
Always a local affection, and cannot infect 
the system. "Specific" treatment by 
mercury and iodine always useless, and, 
in most cases, injurious. 



THE INFECTING CHANCRE. 



Origi 



Always derived from an infecting chancre or 
secondary lesion. 
Anatomical characters. 

Generally single; multiple, if at all, from 
the first ; rarely, if ever, by successive 
inoculation. 

Frequently a superficial erosion ; not involv- 
ing the whole thickness of the skin or 
mucous membrane, of a red color and 
nearly on a level with the surrounding 
surface. Sometimes an ulcer, when its 

Edges are sloping, hard, often elevated, and 
adhere closely to subjacent tissues. 

Surface hollowed or scooped out, smooth, 
sometimes grayish at centre. 

Induration firm, cartilaginous, circum- 
scribed, movable upon tissues beneath. 
Sometimes resembles a layer of parchment 
lining the sore. Generally persistent for 
a long period. 

Pathological tendencies. 

Secretion scanty, chiefly serous ; inoculable 
with great difficulty, if at all, upon the 
patient or upon any person under the 
syphilitic diathesis. 

Less indolent than the chancroid. Pha- 
gedena rarely supervenes and is generally 
limited. 

One attack affords complete or partial pro- 
tection against a second. 
Characteristic gland affection. 

All the superficial inguinal ganglia, on one 
or both sides, enlarged and indurated ; 
distinct from each other, freely movable ; 
painless, and rarely suppurate. Pus never 
inoculable. 
Prognosis. 

A constitutional affection. Secondary symp- 
toms, unless prevented or retarded by 
treatment, declare themselves in about six 
weeks from the appearance of the sore, 
and very rarely delay longer than three 
months. 



TREATMENT. 



It would be well if the physician or surgeon, before undertaking 
the treatment of any disease, could always know how far nature is 
able to dispense with his services. As regards primary sores, there 
can be no question at the present day that they are capable of spon- 
taneous cicatrization without the assistance of art. No statement 



GENERAL TREATMENT. 395 

could be more at variance than this with the opinion, generally- 
received not many years ago, that mercury was the touchstone of 
a chancre, and that the sore that healed without it could not be a 
chancre. This error is now, however, so nearly abandoned that its 
repetition, as in the recent work of a distinguished obstetrician, 
must excite a smile in any one at all conversant with syphilis. I 
do not think it necessary, therefore, to refute it here, but would 
simply call attention to the truth of the converse proposition, as 
important to be borne in mind throughout the treatment of primary- 
sores. To repeat in a more definite manner the statement above 
made in its application both to local and general treatment : — 

Although general treatment by mercury doubtless facilitates the cica- 
trization of some chancres (the infecting), yet it is necessary for the 
accomplishment of this process in none, and in the majority (taking 
chancres in the aggregate) is positively injurious. 

All primary sores, except perhaps the phagedenic, will heal sponta- 
neously without local treatment other than cleanliness, generally within 
a period of a few months, and often within a few weeks, but not 
aliuays with as little detriment, or the same comfort to the patient, as if 
art intervened. 

The office of the surgeon, therefore, is to limit destructive action, 
and thereby preserve important parts ; to hasten cicatrization, that 
the patient's comfort may be promoted, and the danger of the com- 
munication of the disease to others lessened. Another object which 
has generally been regarded as of paramount importance, is the 
prevention of constitutional infection; we shall presently inquire 
how far this can be accomplished in practice. 

I shall consider the treatment of chancres under three heads : 1. 
General treatment ; 2. Abortive or destructive treatment ; 3. Local 
applications. 

General Treatment. — The most important question under the 
head of general treatment relates to the employment of mercury. I 
have already remarked that this agent is not essential to the cica- 
trization of either species of primary sore, but its effect is much 
greater upon one than upon the other ; indeed, if farther proof were 
wanting of their distinct nature, it might be found in the obstinacy 
with which the simple chancre persists, and the readiness with which 
the infecting chancre heals, under the influence of mercury. Judg- 
ing from my own experience, no fact is more patent than this. I 



396 



CHANCRES. 






am so fully convinced of its truth that, in undertaking the treat- 
ment of an indurated chancre, I regard the general treatment given 
to combat the constitutional infection as all-sufficient, and the local 
sore as scarce worthy of attention. So soon as the slightest tender- 
ness of' the gums appears from the use of mercury — and generally 
before that time — the chancre, without local treatment other than 
cleanliness, begins to improve, and rapidly heals in the course of a 
few days. Even in cases in which the local symptoms are unusu- 
ally aggravated, as, for instance, when phymosis is present, causing 
considerable distress to the patient, but not requiring immediate inter- 
ference from threatening gangrene, if specific induration can be felt 
beneath the prepuce, the surgeon may rely wholly upon the inter- 
nal use of mercury as a speedy means of relief. In infecting 
chancres, however, which exhibit a tendency to phagedenic action, 
mercury should be dispensed with, or employed with caution, com- 
bined with a tonic, as iron or quinine, and never be pushed to sali- 
vation. 

On the other hand, I am equally certain that mercury has no 
beneficial influence whatever upon the chancroid, which continues 
in a state of stubborn persistency, or even progresses, after the sys- 
tem is fully under its influence. This statement is not a mere infer- 
ence from the duality of the chancrous virus, but is founded upon 
experience. I was fully convinced of the fact by personal observa- 
tion, and ceased to employ mercury for soft chancres, several years 
before the distinction between the two species was recognized. 
Since abandoning it in my own practice, I have had numerous 
opportunities of observing other surgeons administer mercurials for 
the chancroid, and my former opinion has only been confirmed. A 
few years since, during three weeks' absence from the city, I com- 
mitted five patients with soft chancres to the care of a medical 
friend, and, on my return, found them all salivated, and in every one 
the sore was aggravated. I could relate many similar instances, in 
which patients with simple -sores have passed from other practition- 
ers under my care, after going through a course of mercury without 
the slightest benefit. 

Phagedena, unless in the mild form which sometimes complicates 
the infecting chancre, contraindicates the use of mercury. The 
effect of this agent upon the destructive action of phagedena is most 
disastrous, imparting to it increased power and more rapid progress. 
It is a rule expressed in a few words, but one of great importance 



GENERAL TREATMENT. 397 

to be remembered : " Never give mercury in acute cases of phage- 
dena." 

As regards the use of mercury in primary syphilis, practitioners 
may be divided into three classes: 1. Those who administer it in- 
discriminately in all cases of chancre ; 2, those who limit its use to 
indurated chancres ; and 3 ; those who do not employ it at all in the 
treatment of primary sores. 

The course adopted by the first class is one which has come down 
to us from a time when the utmost confusion reigned in matters of 
venereal ; when gonorrhoea, the simple and the infecting chancre 
were regarded as essentially one ; when each was looked upon as a 
source of constitutional infection ; and instances of escape were 
attributed to the happy influence of mercury. The medical pro- 
gress of the present century has done away with the use of mercu- 
rials in gonorrhoea, but has not been so generally successful as 
regards the chancroid. Yet it is difficult to say on what grounds 
the indiscriminate employment of this mineral in all cases of pri- 
mary sores is still maintained by some practitioners. No fact can 
be better established than that a large proportion of chancres — at 
least three out of every four — are never followed by secondary 
symptoms, even if no treatment at all be employed. Can mercury 
" hinder a syphilitic disposition from forming," as Hunter supposed, 
in the small minority who are really liable to it ? This assumption, 
which arose from ignorance of the natural course of primary sores, 
is now known to be entirely destitute of proof. Is it because it is 
thought to be impossible to distinguish between those chancres 
which will and those which will not terminate in constitutional 
infection? Admitting that this is so, mercury is given to three 
patients unnecessarily in order that it may reach a fourth who 
needs it ; and, on the same supposition, treatment should be deferred 
till secondary symptoms are developed, since there is a complete 
absence of proof that mercury has any less power over the diathesis 
then, than shortly after contagion. I suspect, however, that the in- 
discriminate use of mercury still retains a foothold among the pro- 
fession more from the reputation which it acquired in former years 
and from the force of early teaching and example, than from any 
well-grounded reasons in its favor. 

The objections to this course are conclusive, and may be briefly 
stated. In the first place, it unnecessarily subjects a large number 
of persons to the influence of a powerful agent, which must do 



398 CHANCRES. 

harm if it does no good. Sir Astley Cooper said of the rise of 
mercury in gonorrhoea at Gruy's Hospital : " To compel an unfor- 
tunate patient to undergo a course of mercury for a disease which 
does not require it, is a proceeding which reflects dishonor and dis- 
grace on the character of a medical institution ;" and this remark 
is no less true of a chancre which will never be followed by consti- 
tutional infection than of gonorrhoea, nor less applicable to private 
than public practice. 

In the second place, the duration of treatment adopted by those 
who administer mercury without discrimination is almost neces- 
sarily insufficient to prevent secondary symptoms after a truly 
infecting chancre, but merely delays their appearance, and, mean- 
while, gives the patient a false sense of security. I have endeavored 
to ascertain from surgeons who make no distinction between the 
soft and hard chancre, and from patients who have been under 
their care, for how long a time they usually continue a mercurial 
course. I find, by such inquiry, that some are in the habit of 
giving mercury until the gums are tender — which usually occurs 
within a fortnight — and no longer ; while few persevere beyond a 
month or six weeks, during which time they are satisfied with 
rendering the mouth sore two or possibly three times. The general 
results of their practice justify these limits. Suppose twenty patients 
are thus treated ; fifteen escape and five incur secondary syphilis : 
several of the latter are probably never seen again in consequence 
of passing into the hands of other surgeons ; and thus the sufficiency 
of the treatment in an overwhelming majority is apparently estab- 
lished; unfortunately for this reasoning, fifteen of the twenty 
would have been equally exempt if they had taken no mercury 
at all. 

That a mercurial course faithfully continued for a month or six 
weeks, or even for two months, is not sufficient to prevent the 
occurrence of secondary symptoms in any except a few rare in- 
stances of the infecting chancre, is a truth deduced from my own 
experience, and for the confirmation of which I am willing to refer 
to that of any surgeon who has treated a dozen cases of primary 
sore attended by well-marked induration, and who has kept watch 
of the patients for two years afterwards. Now and then a fortunate 
individual escapes farther trouble, but nearly all present some 
constitutional symptom within a year. Hence, when a patient in 
relating his previous history tells me that he had " syphilis" several 



GENERAL TREATMENT. 399 

years ago, and I learn on inquiry that he had only a chancre for 
which he took mercury for two, four, or six weeks, and that he has 
had no subsequent symptoms, I do not hesitate to infer that his 
sore was in all probability a chancroid, and that his system was not 
infected with syphilis. 

But to return to our subject : this short treatment by mercurials, 
when the chancre is of the infecting species, serves but to retard 
the outbreak of secondary symptoms beyond the usual time of their 
appearance. Unless by the persistence of the induration — the value 
of which those who pursue this course for the most part ignore — no 
one can tell whether the patient had a simple or infecting chancre ; 
whether his continued health at the end of six months is due to the 
nature of the virus or to the effect of treatment ; whether he is safe 
for the future or not. The patient believes himself secure, and may 
marry, suddenly to break out with a syphilicle on his wedding 
journey, or to infect an ovum and through it his wife. On the 
other hand, when the original sore was a chancroid, the surgeon has 
the credit of a cure which he never effected, or the patient's history 
adds to the confusion prevailing in syphilis, if ever he or his off- 
spring incur the suspicion of syphilitic taint, and is perhaps recorded 
in some work on hereditary diseases in connection with other mar- 
vellous cases in which gonorrhoea in one of the parents gave rise to 
syphilis in the children twenty years afterwards without interven- 
ing symptoms. In short, the past, present, and future condition 
of every patient who is subjected to this unphilosophical method of 
treatment, based upon no accurate diagnosis of his disease, and 
calculated to obscure its subsequent history, is liable to remain open 
to doubt and conjecture. 

It is an exceedingly difficult and embarrassing question to decide, 
when a person who had a primary sore several months ago, the 
remaining traces of which are obscure and for which he took 
mercurials under the care of another surgeon, comes to inquire 
whether he may marry with safety. His own account of his case 
may be too indefinite to found an opinion upon. More than three 
months may have passed since the appearance of the chancre, and 
there is no persistent induration of its site, but the inguinal glands 
are suspiciously large without marked induration. Under these 
circumstances it is almost an impossibility to determine whether 
he had a chancroid and has nothing farther to fear ; or whether he 
had a chancre, the traces of which have disappeared and the 



400 CHANCRES. 

natural effects of which have failed to be developed in consequence 
of treatment, but which may yet give him trouble. Unless the 
usual mode of practice of the surgeon who treated him be known ; 
no definite answer can be returned to his inquiry, and he must be 
told to await the developments of time. 

The second of the three classes into which I have divided prac- 
titioners, as regards their use of mercury, employ this agent only in 
cases of primary sore attended by specific induration. This class 
is already very numerous, and is rapidly increasing ; it embraces 
many of our older men who have kept pace with the advance of 
science, and probably all, with but few exceptions, who have de- 
rived their ideas of syphilis from the knowledge of the present, and 
not from that of the past. It is not hazardous to predict that the 
extensive and radical change which has been going on during the 
last ten years in the treatment of primary syphilis, will, in the next 
generation, become universal. It is hardly necessary to say that 
the limitation of mercurials to indurated sores is in accordance with 
the doctrine of the duality of the chancrous virus ; but it should 
be distinctly understood that a belief in this doctrine is not essen- 
tial to the adoption of this practice, which originated long before 
the absolute distinction between the two species of primary sore 
was recognized. 

Many, doubtless, who pursue this treatment, would say : Expe- 
rience teaches us that indurated chancres are certainly followed by 
secondary symptoms ; with regard to other chancres, we cannot tell 
whether they will be or not ; we therefore administer mercury for 
the former, and, in cases of the latter, wait and see whether it will 
be required. This is the mode of reasoning of the surgeons of the 
various London hospitals, where, on the authority of the Medical 
Times and Gazette, " the rule of practice, which is almost universally 
agreed in, is never to give mercury except for the indurated sore 
or its results." 1 The same journal states the grounds upon which 
this practice is based as follows : " In a large majority of sores not 
attended by induration, no constitutional phenomena will follow; 
and to discriminate between those likely to be so followed and the 
harmless class is impossible. There is, therefore, no alternative, 
except we would give mercury very often unnecessarily, but to 
wait in these cases until the real nature of the affection shall have 

» Medical Times and Gazette, Aug. 28, 1858, p. 221. 



GENERAL TREATMENT. 401 

been made manifest." 1 We find, therefore, that the same treatment 
may be adopted by those who attribute to induration a merely 
secondary value, and by those who recognize in it an expression of 
a distinct species of virus. 

There is still a third class of practitioners who abstain from mer- 
cury in all cases of primary sore, whether soft or indurated, until 
secondary symptoms make their appearance. This class is probably 
not very large. The most prominent member of it, so far as I am 
aware, is the distinguished surgeon of Lyons, M. Diday, author 
of the excellent treatise on infantile syphilis. Another is Dr. 
Thadcleus M. Halsted, Surgeon to the New York Hospital, whose 
name adds great weight to this practice. It would naturally 
be supposed that surgeons of this class abstain from mercury in 
consequence of distrust in the prognostic value of induration. This 
is by no means so, however. No one is a firmer believer in the 
distinct nature and symptoms of the two species of chancre than 
M. Diday ; and he abstains from specific treatment in hard chancres 
not from any doubts as to the certainty of constitutional infection, 
but because he believes that the patient will ultimately be better 
off, if the disease is left to follow its natural course ; even in the 
secondary stage he does not employ mercury unless the severity 
of the symptoms compels him to do it. Whatever may be thought 
of this mode of practice, we cannot but be grateful for the valuable 
information relative to the natural history of syphilis which it has 
enabled Diday to give us. 

Dr. Halsted gives me the following history of his adoption of this 
practice. He had already been convinced by experience of the 
injurious effect of mercury upon tubercular subjects, having ob- 
served several cases in which treatment administered for syphilis 
had apparently hastened the development of phthisis in persons 
of this diathesis, when a gentleman belonging to a consumptive 
family applied to him with an apparently well-marked indurated 
chancre. Dr. H. resolved to abstain from mercury until secondary 
symptoms should appear, and directed a course of iodide of potas- 
sium ; and though several years have since elapsed the patient has 
experienced no farther trouble. 2 The success of this case induced 

' Med. Times and Gaz., "Hospital Notes," Jan. 16, p. 62. 

2 I cannot admit that this was a true indurated chancre, the natural sequences 
of which were averted by iodide of potassium. 

26 



402 



CHANCRES. 






Dr. H. to temporize in all cases of primary sore, at the same time 
warning patients of their danger and directing them to report them- 
selves from time to time ; and an experience of many years has 
now convinced him that the effect of a mercurial course in syphilis 
is certainly no less, and is perhaps even more satisfactory when 
treatment is deferred until the appearance of constitutional symp- 
toms, than when administered at an earlier period. 

My own views have already been inferred by the reader. I 
believe that the indiscriminate use of mercury in primary sores is 
unnecessary, unscientific, and reprehensible ; that a chancre which 
will not be followed by secondary symptoms may almost always be 
distinguished from one that will ; that mercury should be adminis- 
tered only when the diagnosis of an infecting chancre is clear and 
unmistakable ; and that in exceptional cases of a doubtful character, 
the patient should be kept under observation without treatment 
until after the usual period of incubation of secondary manifesta- 
tions has passed. I prefer this course to the one adopted by Drs. 
Diday and Halsted, because it generally saves the patient from 
being exposed by the sudden outbreak of a syphilitic eruption, loss 
of his hair and eyebrows, or other symptoms likely to attract the 
attention of his associates ; if these occur after the administration 
of mercury, they are generally somewhat modified and less promi- 
nent; also because mercury is the best means of hastening the 
cicatrization of the infecting chancre, which it is desirable to get 
rid of as soon as possible, in order to diminish the chances of con- 
tagion, as well as to promote the comfort of the patient if the sore 
be excavated — the superficial variety occasioning but little incon- 
venience; moreover, I have seen no reason to believe that treatment 
is more effectual if deferred until after the appearance of secondary 
symptoms, and hence nothing is gained by delay. At the same 
time, I know of no decided objection to the course pursued by 
Diday and others, since the cicatrization of the chancre will take 
place spontaneously, or may be hastened by destructive cauteriza- 
tion ; which, however, is also rejected by Diday in this species of 
primary sore. 

Full directions for the administration of mercury will be given 
in the chapter upon the treatment of general syphilis. 

With regard to the general treatment of uncomplicated cases of 
the chancroid and infecting chancres, little remains to be said in 



GENERAL TREATMENT. 403 

addition to the above remarks on trie use of mercurials. It is im- 
portant, however, that the surgeon should exercise supervision over 
the patient's mode of life, regulate his secretions, and so direct his 
diet, exercise, etc., as to maintain his general health at a normal 
standard; on the one hand forbidding stimulants and excess of 
every kind that inflammatory action may be averted ; and, on the 
other, avoiding depression of the system which would favor the 
progress of ulceration or aggravate subsequent secondary manifes- 
tations. It is not generally necessary to confine the patient to the 
house or to prevent his engaging in his daily avocations, unless 
they be attended by an unusual amount of exercise and fatigue. 
The supervention of inflammation, as in the inflammatory chancre, 
demands antiphlogistic regimen and treatment, proportioned to the 
severity of the symptoms. On the contrary, when gangrene has 
taken place, and in all chancres in weak and broken-down consti- 
tutions, a nourishing diet should be given, and frequently tonics 
and stimulants. 

The general treatment of phagedenic chancres should be based 
upon a knowledge of the cause of the destructive action when this 
can be ascertained. Phagedena most frequently occurs in persons 
debilitated by various causes, as intemperance, irregularity of life, 
want, or a residence in damp, unhealthy apartments ; in these cases, 
nourishing food, the ordinary comforts of life, and the mineral or 
vegetable tonics are required. Scrofula is another fruitful source 
of phagedena, and calls for preparations of iodine and other anti- 
strumous remedies. Moderate doses of opium repeated at short 
intervals, so as to keep the patient gently under its influence, are 
often of essential service in allaying pain, and in controlling the 
progress of the disease. Numerous observers have called attention 
to the beneficial effect of this agent upon ulcerative action, and 
have ascribed to it a decidedly tonic influence. Eodet reports 
several cases of serpiginous chancres which resisted a great variety 
of means, but which yielded to opium. This surgeon commences 
with about one grain of the gummy extract of opium morning and 
night, and gradually but rapidly increases the dose so that the 
system may not become habituated to it before its therapeutic 
effect takes place. He prefers two large doses in the twenty -four 
hours to smaller ones more frequently repeated, in order that diges- 
tion may go on unimpeded in the intervals. Light wines are 



404 CHANCEES. 

largely administered at the same time, and are said to correct any 
tendency to constipation. 1 

In many cases it is impossible to discover the cause of phage- 
dena. The general condition of the patient is good ; all his func- 
tions are duly performed ; and yet his primary sore continues to 
extend. In such cases our chief reliance must be placed upon 
deep cauterization, and the general treatment must be more or 
less experimental. 

The potassio-tartrate of iron is a remedy of great value in phage- 
denic chancres, and in all primary sores in which a tonic is required. 
Kicord calls this preparation the " born enemy" of phagedena, and 
attributes to it an almost specific influence upon ulcerative action. 
I can add my own testimony to that of Eicord and many other 
surgeons in its favor, and would strongly recommend a trial of it 
in the class of cases under consideration. 

K:. Ferri et potassse tartratis §ss. 

Aquae §iij. 

Syrupi §iij. 
M. 

From two teaspoonfuls to a tablespoonful of this solution may be 
taken three times a day, within an hour after meals, and a lotion 
containing the same salt be applied to the ulcer. 

An attack of erysipelas has been known to arrest the progress of 
phagedena and to induce cicatrization of serpiginous ulcers which 
had proved intractable under almost every form of medication. 
An instance of this kind is contributed by M. Buzenet to Eicord's 
Legons sur le Chancre, 2 and several are reported by other surgeons. 

Aboetive and Destructive Teeatment. — Many surgeons 
believe that the infecting chancre is at first a mere local affection, 
and that the general circulation does not become contaminated 
until some days after the appearance of the ulcer, hence that the 
early and complete destruction of the sore is capable of averting 
infection of the constitution. We are therefore advised to cauterize 
a chancre as soon as it appears, and are told that if the caustic be 
sufficiently powerful to kill the tissues to an extent exceeding the 
sphere of specific influence, a simple wound will be left after the 

1 Am. Journal of the Med. Sci., Oct. 1856, from the Bull, de Therap., xlix. 

2 Page 278. 



ABOKTIVE AND DESTRUCTIVE TREATMENT. 405 

fall of the eschar, and our patient will be preserved from constitu- 
tional infection. 

The " abortive method/' as this treatment is called, is said to be 
identical with that adopted in other poisonous wounds, as the bites 
of venomous snakes and rabid dogs, and to be as reasonable in the 
one case as in the other. It is an old practice, which, as shown by 
Fournier, was recommended by John de Yigo in 1508 ; and in more 
modern times it has received the sanction of Hunter. One of its 
chief advocates at the present day is Eicord, whose extensive 
experience and keen powers of observation are of themselves 
sufficient to create confidence in any treatment recommended by 
him. In his Notes to Hunter on Venereal, 1 Ricord states that the 
abortive treatment is always successful when applied not later than 
the fifth or sixth day after contagion ; and that a chancre destroyed 
within this period has never been known to be followed by 
constitutional infection. In his Lecons sur le Chancre, 2 however, 
he places the limit at the end of the fourth day, and it would appear 
from his own statements that it ought to be still more nearly 
approximated to the time of contagion, for he admits that induration 
is sometimes developed as early as the third day, and that this is 
an evidence that constitutional infection has already taken place. 

Prof. Sigmund, of Vienna, whose field of observation is scarcely 
less extensive than Eicord's, is also a firm believer in the efficacy 
of this method, and says that in eleven years' practice, and in more 
than one thousand cases to which he has applied the abortive 
treatment, he has never seen secondary symptoms follow a chancre 
which was completely destroyed within four days ; and that he has 
met with only two doubtful cases in which cauterization as late as 
the fifth day was ineffectual ; and even after this time he thinks it 
will often be successful. 

I have adduced this testimony in favor of the abortive treatment 
before stating my objections to it, in order that the reader may be 
better enabled to judge for himself, and that I may not lead any 
one causelessly to adopt a wrong conclusion. It would certainly 
be assuming a fearful responsibility to arouse unjust suspicions of 
a mode of practice which, if based upon correct principles, may 
save thousands of persons every year from the terrible curse of 
constitutional syphilis. And yet, in spite of this strong testimony, 

1 2d edition, p. 320. 2 P. 206. 



406 CHANCRES. 

I cannot think that the abortive treatment of infecting chancres is 
of any practical valne. I believe that however early the patient 
applies to the snrgeon after the development of an infecting sore 
the mischief is already done. The existence of a period of incuba- 
tion, which I have before endeavored to establish, is one argument 
in favor of this position. If the inoculated point remains in a state 
of quiescence for several days and exhibits no traces of inflammatory 
action, the subsequent appearance of the chancre can only be 
ascribed to changes which have already taken place in the general 
circulation ; and, if this be true, cauterization of the sore will be as 
ineffectual in arresting the action of the virus, as when applied to 
the vaccine pustule, or to the bite of a mad dog which has become 
tumefied or reopened as the earliest symptom of hydrophobia. 

And here we see how defective is the analogy drawn from 
venomous wounds by which it is attempted to sustain the abortive 
treatment of chancres. If a person be bitten by a rabid animal, 
and the part at once excised and cauterized, there is some hope of 
averting farther trouble ; but no one would expect immunity when 
treatment was deferred from one to four days. So with the infect- 
ing chancre, the time to apply abortive treatment with success 
would, if possible, be directly after coitus ; the delay of an hour, 
and probably of a few moments will render it useless. Experiments 
with other morbid poisons prove that absorption is almost instanta- 
neous. Bousquet inoculated the vaccine virus, and immediately 
applied cups and washed the part with chlorinated water without 
preventing the evolution of a pustule. 1 Eenault, Surgeon of the 
Yeterinary School at Alfort, inoculated horses with acute glanders, 
excised the part and applied the actual cautery one hour afterwards, 
yet the animals died of the disease. 2 Similar experiments with the 
sheep-pox virus proved that its absorption does not require more 
than five minutes. 

In many instances of infecting chancre, the conditions under 
which contagion takes place are precisely similar to those in the 
above experiments ; a specific virus is applied to a raw surface, 
produced in the one case by violence in coitus, in the other by a 
lancet. Nor will the course of events be materially changed in 
those instances in which the poison is deposited upon the sound 
integument or mucous membrane, and, at first acting as a simple 

1 Traite de la Vaccine. 2 Academic des Sciences, 1849. 



ABORTIVE AND DESTRUCTIVE TREATMENT. 407 

irritant, gains access beneath, the surface throngh ulceration of the 
epithelium ; since the moment a sore is produced, the virus is in 
the same condition as when originally applied to a rent or abrasion. 

"We may fairly conclude, therefore, that so far as we are justified 
in reasoning from the analogy of one specific poison to another, 
there is no ground whatever for supposing that the syphilitic virus 
can remain in contact with a solution of continuity for several days 
without absorption taking place. But although this argument is 
of very considerable weight, it must be confessed that it is not in 
itself conclusive ; since, although it is highly improbable, it is by 
no means impossible that the phenomena of absorption of the 
syphilitic are different from those of any other known specific poi- 
son ; and the question must after all be finally settled by an appeal 
to facts. 

The value of Eicorcl's and Sigmuncl's experience is very much 
weakened, if not entirely annulled, by several considerations. In 
the first place, the diagnostic symptoms between the two species of 
chancre are never manifest within four days after contagion, so 
that it is clearly impossible for either of these surgeons to indicate 
a single one of their numerous cases as an undoubted instance of 
the prevention of constitutional infection by the abortive treatment. 
The nature of the ulcer might have been determined by reference 
to the sore from which it was derived, but this means of diagnosis 
was unknown at the time their observations were made and was 
consequently never resorted to. In any future investigation of this 
question, it should not be neglected. 

Again, infecting chancres constitute but a small proportion of 
the aggregate of primary sores, so that the " more than a thousand 
cases" adduced by Sigmund are far more imposing in appearance 
than in reality. But a still stronger argument against the admis- 
sion of this testimony is found in the recently discovered period of 
incubation of the infecting chancre, which places the usual time of 
its development beyond the limit assigned by these surgeons to the 
efficacy of the abortive treatment, and thereby renders it extremely 
doubtful whether, in any of the cases upon which they rest their 
assertions, general syphilis would have^ensued, even if no treatment 
whatsoever had been instituted. 1 Eeference has already been made 

1 It does not appear incredible, nor even improbable that Ricord, for more than 
twenty years, should mistake the effect of the abortive treatment, when we recol- 



408 CHANCKES. 

to Diday's investigation of 29 cases of infecting chancre, from which 
it appeared that the average period of incubation was 14 days. In 
28 cases observed by M. Ponset the average was 8 days ; and in 
11 cases collected by Fournier the interval between coitus and the 
appearance of the chancre was 3, 4, 5, 5, 5, 5, 6, 6, 6, 7, and 9 days 
respectively. The average deduced from the aggregate of these 
68 cases is nine clays. 1 

This period of incubation of an infecting chancre, which is a 
strong reason for distrusting the statement of Eicord and Sigmund 
also renders it difficult positively to disprove their assertion by 
facts complying to the very letter with the conditions which they 
require ; but a number of cases are recorded in which destructive 
cauterization within a few days and even a few hours after the de- 
velopment of the chancre, has failed to avert constitutional infection, 
and which are sufficient, at least, to show that the abortive method 
is unreliable. Diclay has thoroughly cauterized chancres four days 
and a half and others five days after coitus, and secondary symp- 
toms have still appeared. In another case, occurring in a patient 
who had watched himself with the greatest care from day to day 
and almost from hour to hour, the chancre was not developed until 
a month after the sexual act, but the abortive treatment was ap- 
plied within six hours of its first appearance ; the sore healed in 
the course of three days, but secondary symptoms appeared three 
weeks afterwards. 2 More recently, 3 Diday has reported several 
additional cases as follows : — 

Case 1. A man, aged 45, somewhat of a syphilophobist, and conse- 
quently very attentive to the condition of his genital organs, consulted 
Diday, Sept. 24th, 1858, for a chancre which he had first observed three 
days before. The sore was at once cauterized with the paste of vegetable 
carbon and sulphuric acid, in use at the Hopital du Midi. 

The patient was seen again Oct. 3, when the chancre was found to have 
healed and to have left a healthy-looking cicatrix. Slight induration of 
a few ganglia in the groins inspired, however, some doubts as to the 
future. 

lect that, although habitually inoculating, during the same period, the secretion 
of primary sores upon the persons bearing them, he never discovered until recently 
that the infecting chancre is not auto-inoculable. 

1 Gaz. Med. de Lyon, 1859, p. 570. 

2 Ibid., March 1, 1858. 

s Annuaire de la Syphilis, annee 1858, p. 134. 



ABORTIVE AND DESTRUCTIVE TREATMENT. 409 

Nov. 8. The cicatrix presented a well-marked mass of induration, and 
the glands of both groins were also evidently indurated; and the patient 
complained of scabs in his hair. 

Nov. 19. A papular eruption of a decided copper color appeared over 
the whole body. 

Case 2. A young man who had been subject to herpes preputials, 
and who had been in the habit of consulting his physician for each re- 
newed attack, presented himself, Sept. 21, 1858, with a small chancre 
upon the integument of the penis, which had existed but two days only. 
Canquoin's paste was at once applied and left on the ulcer for two hours. 

A week after, he was apparently well, but a slight hardness, like a grain 
of millet seed, felt when the cicatrix was pressed between the fingers, ren- 
dered the prognosis somewhat doubtful. 

Oct. 27. Syphilitic roseola began to appear upon the abdomen, and 
by Nov. 4, became general and unmistakable. The patient also had acne 
capitis, engorgement of the cervical ganglia, headache, etc. 

Case 3. A young man, who, from former experience, was familiar 
with the appearance of chancres, sought advice Oct. 14, 1858, for a small 
abrasion, which, as he stated, appeared only twenty-four hours before. It 
was immediately burnt with the carbo-sulphuric paste. 

Oct. 28. The sore had cicatrized but had left well-marked induration, 
which also involved the inguinal ganglia. 

Nov. 26. He presented a papular syphilitic eruption, and scabs upon 
the hairy scalp. 

The following case is reported by M. Langlebert. 1 

Case 4. A student of medicine, who was thoroughly informed upon 
all subjects connected with syphilis, consulted Langlebert for a small 
ulcer behind the corona glandis which he was certain had appeared only 
two days before. The sore was very superficial, scarcely larger than the 
head of a pin, was not indurated, nor accompanied by engorgement of 
the inguinal ganglia. It was cauterized the same day with nitrate of 
silver, and healed in less than a week. 

No induration appeared in the groins, but two months after constitutional 
syphilis declared itself. 

The above cases are sufficient to show that the early destruction 
of an infecting chancre is incapable of averting general syphilis. 
Indeed, as I have previously stated, the existence of a period of in- 
cubation, during which the inoculated point remains in a state of 

1 Moniteur des Hopitaux, Dec. 21, 1858. 



410 CHANCRES. 

quiescence, proves that the chancre itself mnst be looked upon as 
the effect of changes which have already taken place in the general 
circulation. We can, at this time, no more hope to arrest the action 
of the virus by the abortive treatment, than we could expect, by 
destroying a vaccine pustule, to restore the system to the same con- 
dition as before vaccination. 

I have thus endeavored to show that destructive cauterization is 
ineffectual for the purpose for which it is often employed, viz., the 
prevention of constitutional syphilis ; and I believe it should be 
abandoned as useless, and as subjecting the patient to unnecessary 
pain, whenever there is reason to suppose that the chancre is of the 
infecting species. In doubtful cases, however, we may still resort 
to it, for fear the sore may be a chancroid, which can be much 
more readily destroyed at an early than at a late period of its 
existence. 1 

Several surgeons have endeavored to discover some single sub- 
stance or compound capable of neutralizing the chancrous virus, 
and k yet not so powerful as ordinary caustics, so that it might be 
used with safety by any one after exposure to bathe the genital 
organs ; but such attempts have not been very successful. Eoclet 2 
has experimented with the following mixture and found that when 
applied to the puncture of an artificial inoculation, it undoubtedly 
prevents the development of a soft chancre, provided that a drop of 
the fluid remains in contact with the part for fifteen or twenty min- 
utes ; but it would be impossible to induce men generally to adopt any 
prophylactic measure requiring so long an application. 

R:. Aquae destillatae ^j. 

Ferri perchloridi, 

Acidi eitrici, 

Acidi hydrochlorici, aa 3j. 
M. 

Destructive Method. — Though the abortive and destructive methods 
of treatment involve the use of the same means, yet the object of 

1 A number of surgeons have expressed their disbelief in the efficacy of the 
abortive treatment as a means of preventing constitutional infection, among whom 
may be mentioned Diday, Rollet, Clerc, Dron (Annuaire de la Syphilis, 1858, p. 
202), Erichsen (Science and Art of Surgery, 2d London ed., p. 447), Vidal (Treatise 
on Venereal Diseases, 1st Am. ed., p. 198), Langston Parker (Modern Treatment of 
Syphilitic Diseases, Am. ed., 1854, p. 107), Harrison (Pathology and Treatment of 
Venereal Diseases, 1860, p. 129), and Dr. Wm. H. Van Buren, of this city. 

2 Compte Rendu du Service Chirurgical de l'Antiquaille, 1855, p. 74. 



DESTRUCTIVE METHOD. 411 

each is different. The abortive treatment regards a chancre as the 
precursory symptom of syphilis, and endeavors by its removal to 
prevent constitutional infection. The destructive method has refer- 
ence only to the local sore and its immediate neighborhood, and 
aims to limit the duration and extent of the ulcer, and to prevent 
successive inoculations, the formation of virulent buboes, and the 
supervention of phagedena. 

Destructive cauterization as a means of hastening the cicatriza- 
tion of chancres, and not for the purpose of preventing constitu- 
tional infection, was first employed by Eichond cles Brus in 1826. 
This surgeon limited its use to the commencement of primary 
sores, but it has since been extended by Eicord to every stage in 
the existence of these ulcers, with the exception of the reparative 
period. 

The destructive method may be applied either to the chancre or 
to the chancroid, but is not generally required in the former, which, 
as already stated, readily cicatrizes under the use of mercury given 
to combat the constitutional infection. In applying it to cases of 
a doubtful character, in which some prove to be infecting chancres, 
the effect of the treatment is found to be the same as in the chan- 
croid : the specific is transformed into a simple sore which rapidly 
heals, though induration supervenes either before or after complete 
cicatrization. 

But this simple method finds its chief application in the simple 
chancre or chancroid, in which the influence of the virus is con- 
fined to the ulcer and the tissues immediately surrounding it ; and 
if these be all included in the eschar produced by the caustic, the 
whole disease will be removed. Destructive cauterization is the 
only means which can be depended upon to effect a speedy cure of 
the chancroid. Astringent and disinfecting lotions, and cleanliness 
may prevent inoculation of neighboring parts, but have little, if 
any, power to control the duration or extent of the ulcer itself, 
which pursues its natural course unchecked and cicatrizes only after 
several weeks' or months' duration, unless eradicated by caustic. 
Hence destruction of the primary sore is the most valuable means 
that we possess of averting phagedenic ulceration, and of arresting- 
its progress when once it has supervened. 

The destructive method, if applied sufficiently early, prevents the 
occurrence of virulent buboes by removing the source from which 
the virus enters the lymphatics ; but if deferred until a bubo has 



412 CHANCRES. 

commenced; the latter goes on to suppuration unchecked, and may 
furnish inoculable pus in the same manner as if the chancroid had 
been allowed to remain. Even the sympathetic bubo is often 
benefited by destruction of the primary sore and undergoes resolu- 
tion. 1 

Destructive cauterization is impracticable when the chancroid 
cannot be fully exposed, as in consequence of phymosis, conceal- 
ment within the urethra, os uteri, etc. It is inadmissible in ulcers 
situated directly over the urethra either in the male or female on 
account of the danger of opening this passage ; for similar reasons, 
in chancroids of the deeper portions of the vagina, the walls of 
which are in contact with the bladder, rectum, and peritoneum ; in 
those upon the margin of the meatus, from the fear of the cicatrix 
occasioning stricture ; and finally in all cases in which the presence 
of other chancres in the neighborhood, which cannot be subjected 
to the same treatment, would expose the wound after the fall of 
the eschar to a second inoculation. 2 

An attempt to remove chancres by the knife is rarely successful, 
since, however carefully the secretion of the sore may first be re- 
moved, enough usually remains to inoculate the fresh wound. For 
this reason, excision should be employed only when a cutting 
operation is rendered necessary, as by the presence of phymosis 
and threatening gangrene; and the knife should be carried as wide 
as possible from the specific sore, and the bleeding surface be freely 
cauterized with nitrate of silver or nitric acid. On the contrary, 
the application of caustic leaves the tissues for a time protected by 
an eschar, and is, therefore, almost always to be preferred to the 
knife. 

Nitrate of silver is too feeble a caustic to be employed except at 
the commencement of a chancroid, or in wounds and abrasions im- 
mediately after a suspicious connection, before the surrounding 
tissues have become infiltrated with the virus. It is chiefly used 
for the purpose of destroying the pustule which appears on the 
second or third day after a successful inoculation. A fragment of 
the solid crayon corresponding in size to the excavated ulcer which 
is exposed by the removal of the epidermis, is pressed into it and 

1 Rollet, Gaz. Med. de Lyon, March 1, 1858. 

2 De la Methode Destructive des Chancres, par M. Dron ; Annuaire de la Syphi- 
lis, annee 1858, p. 202. 



DESTEUCTIVE METHOD. 413 

allowed to remain until it comes away with the small eschar which 
is formed. The simple wound which is left speedily cicatrizes. 

For the fully developed chancroid a stronger caustic is required, 
as nitric or sulphuric acid, potassa cum calce, the pernitrate of 
mercury, chloride of zinc, or the actual cautery. Of these, strong 
nitric acid and Vienna paste, from the convenience of their appli- 
cation, have deservedly come into the most general use. 

Nitric acid is preferably applied by means of a glass rod with a 
rounded extremity ; a " drop bottle," with a tapering glass stopper, 
the point of which extends nearly to the bottom of the flask, is still 
more convenient ; but a simple piece of wood, as an ordinary lucifer 
match, will answer. Brushes of fine glass are objectionable, since 
the filaments are liable to break off upon the surface of the sore 
and excite irritation. The pain is for an instant very severe when 
the acid first touches the ulcer, but becomes much less acute on 
subsequent applications, of which there should be several in order to 
render the destruction complete. I usually employ several minutes 
in making these applications, watching the effect produced, and 
judging by the changes which take place in the tissues when enough 
has been applied. Any residue should be carefully removed or 
neutralized by an alkali, and the neighboring surfaces be protected 
from contact by the interposition of dry lint. A water-dressing 
may be substituted as soon as suppuration takes place. 

After the fall of the eschar, the surface is still covered for a short 
time with a slimy secretion, but this soon clears off, and any in- 
flammatory engorgement produced by the caustic subsides, leaving 
a healthy looking wound, which should be protected from the urine 
and leucorrhoeal discharges in order to insure its speedy cicatriza- 
tion. If any symptoms of a chancroid remain, the cauterization 
should be repeated. 

I am convinced that nitric acid is far superior to the nitrate of 
silver which is so commonly employed in the cauterization of chan- 
cres, and that the latter should never, as a general rule, be applied 
for this purpose except at the very commencement of the ulcer. 
Any one may convince himself of this truth by a comparative trial 
of the two agents. The same sore which continues to extend under 
the application of the nitrate of silver, will speedily cicatrize under 
the use of nitric acid repeated, if necessary, every second or third 
day. Any fears which might be entertained that the frequent 



414 CHANCRES. 

application of so powerful a caustic would do mischief appear to 
be groundless. 

The liquor hydrargyri pernitratis may be applied in a similar 
manner ; I am not aware, however, that it possesses any advantages 
over nitric acid, and it is attended with some danger of producing 
salivation. 

Potassa cum calce made into a paste and spread upon the chan- 
croid, where it is allowed to remain from five to fifteen minutes, is 
another convenient mode of applying the destructive method. 

Kicord has of late years employed a paste composed of vegetable 
carbon mixed with strong sulphuric acid. Its advantages are said 
to be that it forms a crust which closely adheres to the tissues, and 
does not fall off until the sixth or eighth day, when cicatrization is 
far advanced. I have used the carbo-sulphuric paste in a few in- 
stances, but not in a sufficient number to speak decidedly of its 
merits. Thus far, it has not appeared to me to be superior to other 
caustics, nor so convenient ; and it is, I think, little used elsewhere 
than at the Hopital du Midi. 

A valuable caustic, judging from the high encomiums bestowed 
upon it by many French surgeons, especially of the Lyons school,, 
is to be found in " Canquoin's paste," composed of equal parts of 
chloride of zinc and flour, which was first recommended for the 
destruction of the chancroid by MM. Eollet and Diday. The only 
serious objection to it is the difficulty of preserving it, owing to 
the deliquescent properties of the chloride. If carefully prepared, 
however, and protected from moisture, it may be kept indefinitely. 
Some, which I have repeatedly used with very satisfactory results, 
was made by an expert druggist over a year ago from Squibb's 
chloride of zinc, and, surrounded by tinfoil, has been kept in a 
drawer without becoming soft. 

Debauge recommends that fresh chloride of zinc should be pre- 
pared for the purpose by dissolving laminse of the pure metal in 
hydrochloric acid, filtering the solution through carded cotton and 
evaporating it by a gentle heat ; I believe, however, that chloride 
of zinc obtained at the druggists' and thoroughly dried over a spirit 
lamp, is equally as good. 

The finely-powdered chloride should be intimately mixed with 
an equal quantity of flour, which has also been dried by heat, and 
alcohol added drop by drop until a paste is formed, which is to be 
spread in a thin layer upon cloth, and again subjected to gentle 



DESTRUCTIVE METHOD. 415 

heat. Should deliquescence subsequently take place, the paste may 
readily be dried again without losing its caustic power. 1 

When required for use, a disk, corresponding in shape to the 
chancroid, and slightly exceeding it in size, is cut out and retained 
upon the surface, previously cleansed of matter, from one to three 
hours, and in large or phagedenic ulcers for five or six hours. Two 
hours is the average duration required for ordinary cases. The 
patient should keep his bed until the paste is removed; and, since 
only one surface of the plaster is covered with caustic, the prepuce 
may be drawn forwards, when the sore is situated upon its internal 
surface, or upon the glans, without danger of injury to the sound 
tissues. 

The advantages of Canquoin's paste are its facility of application 
and freedom from the danger to which all liquid caustics are liable 
of involving the sound tissues ; the small amount of pain which it 
excites ; and the possibility of graduating the depth of its destructive 
action, which is directly proportioned to the length of the applica- 
tion. Diday has especially insisted upon the absence of pain, and 
says that he has frequently been told by patients that they felt only 
a slight pricking sensation ; Eollet states that it is not painful, ex- 
cept when applied to sores involving the frsenum. 

Some oedema is observed after the cauterization, and also inflam- 
matory hardness of the base of the sore, which must not be mis- 
taken for specific induration. The eschar usually falls off about 
the fourth or fifth day ; and of forty-one cases of which a record 
was kept by Eollet, the shortest time required for complete cicatri- 
zation was eleven days and the longest fifteen days. 2 Canquoin's 
paste has also been employed for the destruction of chancres suc- 
ceeding the opening of virulent buboes. 

Eollet has recently applied the actual cautery to serpiginous 
chancres, and although he reports but two cases, 3 yet the results 
were so satisfactory as to encourage us to hope that an effectual 
mode has at length been found of treating these ulcers, which have 
long been the opprobrium of surgery. 

In one case, the ulcer, of ten months' duration, extended from 

1 Debauge, Traitement des Chancres Simples et des Bubons Chancreux par la 
Cauterisation au Chlorure de Zinc ; These de Paris, 1858, p. 12. 

2 Caz. Med. de Lyon, Dec. 15, 1857. 

3 Note sur la Destruction du Chancre Phagedenique Serpigineux par la Cauteri- 
sation Actuelle ; Annuaire de la Syphilis, 1858, p. 116. 



416 CHANCRES. 

the root of the penis to the spine of the ilium and encroached upon 
the integument of the abdomen, thigh, and scrotum : various con- 
stitutional remedies had been tried without effect, but complete 
cicatrization took place in one month after the application of the 
cautery. In another case, which had persisted for eight months 
and which had been ineffectually treated by general remedies and 
local cauterization with Canquoin's paste, the success attending the 
use of the hot iron was no less remarkable. 

Although constitutional cachexia is the chief cause of phage- 
dena, yet the abundant secretion from a serpiginous ulcer and the 
excessive pain attending it, often more than counterbalance the 
effect of tonics, nourishing diet and other hygienic measures. By 
destroying the specific ulcer, these causes of debility are in a great 
degree removed, and the system rapidly yields to the influence of 
constitutional remedies. 

The caustics above mentioned are not sufficiently powerful or 
rapid in their action effectually to destroy the whole extent of phage- 
denic chancres. If the smallest loophole be left from which virulent 
pus can proceed, it will inoculate the wound remaining after the fall 
of the eschar, and the only effect of the treatment will be to increase 
the size of the ulcer. It is evident, therefore, that the destruction 
of the ulcer, in order to be a benefit and not an injury, must be 
thorough and complete. Some hesitation may be felt in applying the 
actual cautery to so extensive a surface, but when the gravity and 
obstinacy of the disease are considered, it must be confessed that 
almost any means is justifiable which holds out a fair promise of cure. 

The patient should be rendered insensible by means of an anaes- 
thetic, and cauterizing irons of different shapes and sizes be raised 
to a white heat. 

Eollet directs that the ulcer should first be cleansed by washing- 
it copiously with water, removing all adherent matter and then 
drying it. Every portion of the secreting surface should now be 
deeply cauterized, carrying the hot iron into every nook and sinus, 
and paying special attention to the parts overlapped by the skin of 
the edges. These flaps of integument should be cauterized not only 
upon the under, but also upon the outer surface, so as to be for the 
most part destroyed. A cold water-dressing is afterwards applied, 
and the patient, on waking, does not suffer much more than he did 
before the operation. When suppuration commences, Goulard's 
extract or aromatic wine may be added to the lotion. 



TOPICAL APPLICATIONS. 417 

Topical Applications. — We now proceed to consider the 
local treatment of chancres by other means than destructive cau- 
terization. 

I have already stated that little dependence can be placed upon 
any therapeutic effect from the ingredients of the lotion or dress- 
ing applied to a primary sore. I do not mean to imply, how- 
ever, by this remark that the local treatment of chancres is unim- 
portant. Neglect in this direction may result in decided injury ; 
while proper attention will put the ulcer in the most favorable 
condition for cicatrization to take place. If the secretion be allowed 
to accumulate and stagnate — if scabs be permitted to form under 
which matter may burrow, ulcerative action will be favored, and 
also (in case of the chancroid) successive inoculations in the neigh- 
borhood. These evils may be obviated by cleanliness, and by such 
form of dressing as will absorb or remove the pus as fast as it is 
secreted, assisted by astringents or disinfectants for the purpose 
either of hardening the surrounding surface or neutralizing the 
virus. But this, I think, is about all that local applications can 
accomplish. To attribute to them specific virtues, as, for instance, 
to suppose that mercurial applications possess any power over the 
sore because it is a chancre, is to my mind absurd. In short, topical 
remedies have the same influence upon a chancre as upon simple 
ulcers, and do not affect its specific character. 

It is highly desirable to aim at simplicity in the local treatment 
of primary sores; though applications must be varied somewhat to 
correspond with the situation and species of the ulcer, and the 
copiousness of the discharge. 

Chancres situated beneath the prepuce, when this fold of integu- 
ment habitually covers the glans, may be dressed with dry lint, 
which will be sufficiently moistened by the natural secretion of the 
part. Indurated chancres are not liable to give rise to successive 
sores in the neighborhood, and hence astringents and disinfectants 
are rarely required. In the superficial variety upon the internal 
surface of the prepuce, the interposition of a small piece of dry linen 
between the glans and prepuce is all-sufficient. In the more exca- 
vated form which is commonly met with in the furrow at the base 
of the glans, scraped lint is preferable, since it is a better absorbent. 

Lotions are necessary when the sore is situated upon the external 
integument, in order to keep it moist and prevent the dressing from 
27 



418 CHANCEES. 

adhering to the surface, and this object may be still farther pro- 
moted by covering the dressing with oiled silk. 

In most cases, the lotion may consist of simple water or glycerine ; 
when medicated, such ingredients should, as a general rule, be added 
as will not leave a deposit or change the aspect of the sore, and 
thus render its condition obscure. The following formula are among 
the best : — 

R. Liquoris sodse chlorinatse 5j« 

Aquae purse §ij. 
M. 

R. Acidi nitrici diluti 5j« 

Aquae purse §viij. 
M. 

R. Yini aromatic! §j. 

Aquse §iij. 
M. 

A formula for a convenient substitute for the French aromatic 
wine may be found on page 167. The strength of these lotions 
must be adapted to the sensibility of the part, which varies in 
different cases. They should never be so strong as to excite pain 
or produce irritation. 

The black wash, composed of from one to three scruples of calo- 
mel to four ounces of lime-water, is a favorite application with 
many surgeons. The dark-colored sediment in this mixture is an 
oxide of merciiry, and is inert unless it affords mechanical protec- 
tion to the sore. In my opinion, black wash is a less cleanly and 
less desirable lotion than those before mentioned. 

A solution of the potassio-tartrate of iron, in the proportion of 
from two to eight drachms of the salt to six ounces of water, is 
much employed by Eicord, especially in the treatment of phage- 
denic chancres. In many cases this application acts very favorably ; 
while in others, I have found that the sore became covered with a 
dingy coating of coagulated matter, which obscured its condition, 
and required to be removed by a water dressing. I have only 
observed this unpleasant effect when the application has been 
made to chancres beneath the prepuce, and have been inclined to 
attribute it to a combination of the iron with the smegma prwputii. 
The dressing of primary sores, and especially of phagedenic chan- 
cres, most recently adopted by Eicord, is the stearate of iron, which 
may be prepared in the following manner. Dissolve castile soap 



TOPICAL APPLICATIONS. 419 

in a sufficient quantity of water, and gradually add a salt of the 
peroxide of iron, as the liquor ferri perchloricli or liquor ferri per- 
sulphatis, until it ceases to form a precipitate, which collects in a 
tenacious mass upon the surface. This mass, which is a stearate 
and oleate of the peroxide of iron, should be freed from impurities 
by being washed or melted in fresh water, and, either pure or 
mixed with lard, is to be spread upon lint and applied to the sur- 
face of the chancre. Some of this pomade has been kindly pre- 
pared for me by Mr. Ferdinand F. Mayer, a skilful chemist of this 
city, but I have not as yet experimented with it. 

Lotions of acetate of lead are objectionable, since this salt is 
decomposed when brought in contact with the animal secretions, 
and an insoluble albuminate of lead, which is with difficulty re- 
moved, is deposited upon and incrusted in the tissues. 

Unguents are less desirable applications than lotions, and should 
only be employed when, from the position of the sore, or from the 
necessarily long interval between the dressings — as at night or 
during a journey — the evaporation of a water dressing cannot be 
prevented, even with the assistance of oiled silk and glycerine. 
Mercurial ointment, which, as procured in the shops, is generally 
rancid or rapidly becomes so, is irritating and especially objection- 
able. One of the following formulae may be employed when an 
unctuous dressing is required. The first is much used in French 
hospitals. 

fy. Cerati simplicis 5J. 

Tincturse opii 5j« 

Caloraelanos gr. xxxvj. 
M. 

P^. Balsami Peruviani, 

Olei ricini, aa |j. 
M. 

P^. Ung. zinci oxidi |j. 

Pulv. opii 3J. 
M. 

The frequency with which local applications are to be changed 
must be determined by the copiousness of the secretion, which 
should not be allowed to collect and stagnate, or (especially in case 
of the chancroid) extend to surrounding parts. 

Before one dressing is soaked with the discharge, another should 
be substituted. If the first adhere to the surface, it should be care- 



420 CHANCEES. 

fully moistened before attempting its removal, in order to avoid any 
abrasion, which, by subsequent inoculation, would increase the size 
of the sore. The patient should also be directed not to cleanse the 
ulcer itself, but simply to remove the discharge from the neighboring 
parts by touching them gently (without friction) with a soft piece 
of linen. The dressing of most uncomplicated chancres need be 
renewed only two or three times a day, but phagedenic ulcers re- 
quire a much greater frequency. 

During the process of cicatrization, exuberant granulations may 
spring up and require repression by pencilling with a crayon of 
nitrate of silver. A superficial application of this agent is also 
beneficial in relieving the irritability and pain of some chancres in 
the progressive and stationary periods. 

Other applications than those now mentioned may be required in 
the treatment of primary sores. For instance, in chancres attended 
by much inflammation, leeches to the groins or perineum, and poul- 
tices or sedative lotions, are of service. Pain should be relieved 
by the exhibition of opium in large doses internally, and by its 
application externally. 

The detached edges of phagedenic chancres should be removed 
by destructive cauterization with Vienna paste, nitric acid, or the 
actual cautery. 

The above remarks on the treatment of chancres may be summed 
up as follows : — 

1. In the treatment of all primary sores, the general health is to 
be maintained as nearly as possible at the normal standard; avoid- 
ing both a depressed and stimulated condition of the system. Local 
applications should be simple and unirritating. Cleanliness should 
be carefully observed. 

2. Simple chancres do not require the administration of mercu- 
rials, either as a preventive of constitutional infection or to promote 
cicatrization of the ulcer. The most effectual treatment is deep 
cauterization with a powerful caustic, as fuming nitric acid, repeated 
as often as may be found necessary. 

3. The internal use of mercury is justifiable only in undoubted 
cases of infecting chancre ; and, in nearly every case of this species 
of primary sore, is the only treatment required. The abortive 
treatment at the earliest period at which the sore can be detected, 
is ineffectual in preventing constitutional infection. 

4. When in doubt as to the nature of a chancre, treat it as be- 



CHANCRES OF THE FR^NUM. 421 

longing to the simple species, and keep the patient under observa- 
tion until the period of incubation of secondary symptoms has been 
passed in safety. 

5. Inflammatory chancres are to be treated by rest, low diet, and 
other antiphlogistic measures, so long as the acute symptoms con- 
tinue; if gangrene occur, tonics and stimulants will be required. 

6. The treatment of phagedenic chancres consists in attention to 
the hygienic condition of the patient, nourishing diet, tonics, stimu- 
lants, opium, and deep cauterization by means of nitric acid, Vienna 
or Canquoin's paste, or the actual cautery, followed by appropriate 
lotions, as the potassio-tartrate of iron. Mercurials are highly 
detrimental in acute phagedena, and are rarely of benefit in any 
case in which this complication is present. 

Special Indications from the Seat of Chancres. — The seat 
of chancres often modifies their symptoms and necessitates changes 
in the treatment. 

Chancres of the Frsenum. — Chancres of the fraenum are espe- 
cially painful, persistent, and exposed to hemorrhage. They may 
commence either upon the free margin or upon the base of the 
bridle. In the former case a rent or fissure, the result of violence 
during coitus, has probably been inoculated; and the resultant 
chancre gradually eats away the whole bridle, and hollows out a 
narrow longitudinal groove upon the under surface of the glans, 
giving great annoyance, persisting indefinitely, and resisting ordi- 
nary modes of treatment. Again, chancres of the fraenum may 
proceed from primary sores in the neighborhood, which exhibit a 
remarkable tendency to involve the bridle, if situated near it. In 
this case the base of the fraenum is first attacked, and often becomes 
perforated from side to side ; the chancrous opening gradually en- 
larges, extends to the free margin, and, as in the former case, pro- 
bably destroys the whole bridle. The fraenum is copiously supplied 
with blood, and exceedingly sensitive ; hence chancres of this part 
are very liable to bleed and give rise to much suffering. Their 
persistency and destructive tendency are due to the frequent rupture 
of the longitudinal fibres of the fraenum, occasioned by the constant 
motion to which it is exposed, in walking, handling the penis 
during micturition, in erections, etc. Minute rents are thus caused 
in the sore which become inoculated and increase its depth ; and 
ulcerative action goes on until the whole bridle is destroyed, 



422 CHANCEES. 

including the portion buried in the under surface of the glans ; and 
hence the fossa already referred to. 

In the treatment of these chancres, the patient should be directed 
to avoid all motions of the part which will stretch the fraenum ; 
the glans should not be uncovered except to dress the sore, and 
even then no farther than is absolutely necessary to insert the 
dressing. If the chancre threaten to destroy the whole bridle, time 
will be gained by accomplishing the same at once by means of 
caustic. When perforation has taken place, the remaining portion 
of the bridle should be divided with scissors, and the raw surfaces 
freely cauterized. The flow of blood in this operation is often 
troublesome, and may be avoided by previously passing a double 
ligature through the opening and tying each thread at either 
extremity of the fraenum, all of which should be removed. Diday 
heats one blade of a dull pair of scissors over a spirit lamp, and 
passing the opposite blade through the opening to serve as a support, 
divides the fraenum by the actual cautery. 1 

Urethral Chancre. — " Gonorrhoea virulenta" either proceeds from 
a urethral chancre alone, or consists of the discharge of ordinary 
gonorrhoea, which has acquired specific properties, from being 
mingled with the secretion of a chancre or secondary lesion. 
There is no other "gonorrhoea virulenta" than this ; and as the 
name has usually a very different and erroneous interpretation, it 
should be banished from our nomenclature. Terms like this are 
clogs upon the feet of science. 

By referring to the table of the seat of chancres on page 356, it 
is seen that of 814 chancres observed at the Hopital du Midi, 41 
involved the meatus, and 20 were situated within the urethra, at a 
greater distance than was visible on forced separation of the lips. 
Attempts have been made to determine the frequency of urethral 
chancres by artificial inoculation of gonorrhoeal discharges, but this 
test, as we shall presently see, may be fallacious. 

As might be supposed, urethral chancres are most frequently 
found near the meatus ; but they may be seated in any portion of 
the canal, and, in rare instances, even in the bladder. Eicord 
presented to the Academy of Med. of Paris 2 two specimens of 
phagedenic chancre involving the deeper portions of the urethra 

1 Du Chancre Primitif du Freiu de la Verge ; Gazette Hebdomadaire, Oct. 19, 
1855, p. 749. 

2 Bull, de l'Acad. de Med., 1838, t. ii. p. 506. 



UKETHKAL CHANOEE. 423 

and bladder, in each of which the disease had been recognized 
during life by the successful inoculation of the urethral discharge. 1 
Vidal, with strange inconsistency, denies the possibility of these 
cases, and then reports a similar one of his own ! 2 Many chancres 
of the fossa navicularis are visible on forced separation of the lips 
of the meatus. For the purpose of exploring this portion of the 
urethra, I am in the habit of using Toynbee's ear-speculum, the 
uniform calibre of the extremity of which permits its introduction 
for about an inch, and if the patient be placed in direct sunlight, an 
excellent view of the lining membrane for this distance may be 
obtained. 

When situated beyond the field of vision, urethral chancres are 
recognized with greater difficulty. Successful inoculation of the 
discharge will determine the presence of a chancroid, which, if the 
surrounding parts be much inflamed, may sometimes be felt on 
external palpation. Auto-inoculation, as already seen, is not a test 
of the true syphilitic or infecting chancre, and hence cannot be 
relied on; but this species may be recognized in most cases by 
other symptoms. The specific induration which surrounds it is 
often perceptible to the touch; the glands of the groin present 
their characteristic changes; and hard, indurated cords (specific 
lymphangitis) may sometimes be felt extending from the seat of 
the chancre towards the root of the penis. It is evident, however, 
that unless the surgeon be on his guard, these symptoms may escape 
notice ; there are certain phenomena in an apparent case of gonor- 
rhoea which should lead him to suspect and search for a urethral 
chancre ; these are the small quantity and dark color of the discharge, 
its mixture with blood, and the location of the pain, especially 
during the passage of the urine, at a fixed point. 

It is unnecessary to insist upon the fact that urethral chancres 
sometimes give rise to constitutional infection, the origin of which 
is unknown to the patient, who may honestly declare that he has 
never had a chancre. 

Urethral chancres, so near the meatus as to be visible, are to be 
treated like other primary sores; the dressing, with a thread 
attached to facilitate its withdrawal, being inserted by means of a 
probe after each act of micturition. Deep urethral chancres are not 

1 These cases are figured in Ricord's Notes to Hunter. 

2 Treatise on Venereal Diseases, 1st Am. ed., N. Y., 1854, p. 209. 



424 CHANCRES. 

susceptible of much local medication. Injections of a solution of 
nitrate of silver have been recommended, but neither in this form 
nor when the solid crayon is applied by means of Lallemand's 
instrument, can this agent destroy the specific sore, and it only 
serves to irritate, as when applied to external chancres. Topical 
applications must therefore be limited to injections containing 
opium, glycerine, or some mild astringent. If the chancre be 
indurated, give mercurials ; if simple, abstain from specific treatment ; 
relieve inflammation, if necessary, by leeches to the groin; if 
abscesses form, open them early ; and, in all cases, guard against 
erections which tear and irritate the sore. 

Chancres of the Vagina and Os Uteri. — Chancres of the deeper 
portions of the vagina cannot be treated by destructive caiiterization, 
owing to the proximity of important parts — an objection which does 
not apply to those of the os uteri. The local applications employed 
in external chancres may be made through a speculum. 

It is important to recollect that induration is not so constant a 
symptom of the infecting chancre in women as in men ; hence in 
establishing the diagnosis, we are often obliged to rely almost 
exclusively upon the condition of the inguinal ganglia, or even wait 
until the normal period for the appearance of secondary symptoms 
has passed. 

According to Gosselin, hypertrophy of the labia major a, whether 
accompanied or not by that of the labia minora and some of the 
carunculae myrtiformes, is so exclusively an effect of chancres in the 
neighborhood of the vulva, that its presence is sufficient to justify 
the conclusion that a woman has at some previous time had primary 
syphilis. 1 

Chancres of the Anus and Rectum. — Chancres of the margin of the 
anus are liable to be mistaken for fissures. They are attended by 
much pain, especially during the passage of the feces, which should 
always be rendered liquid by a mucilaginous injection. It is 
sometimes advisable after clearing out the bowels, to thoroughly 
cauterize the chancre, and to confine the patient to bed and a low 
diet, and administer opiates for the purpose of preventing any 
farther stools until cicatrization has taken place. 

It is a fact worth remembering that an infecting chancre of the 
anus or rectum causes induration of the more external inguinal 

» Arch. Gen. de Med., Dec. 1854, p. 684. 



CHANCRE OF THE MOUTH. 425 

ganglia, which are situated near the anterior and superior spine of 
the ilium. 

Chancres about the Mouth. — Chancres of the lips are generally 
superficial, and very rarely excavated unless subjected to irritation. 
Their outline is ovoid, the longer axis parallel to the buccal fissure, 
and their general aspect is the same as that of the superficial 
infecting chancre, to which variety they belong. When they 
involve the labial commissure they are divided into two portions, 
separated by a deep ulcerated fissure at the angle of the mouth. 

Chancres upon the tongue are most frequent near its extremity. 
They are generally of small size, and are more deeply excavated 
than those upon the lips. Chancres have also been observed upon 
the gums, internal surface of the cheeks, palate, and tonsils. 

Induration is nowhere more fully developed than upon the lips, 
except, perhaps, in the balano-preputial furrow; and is often so 
massive as to cause the lip to protrude and disfigure the countenance. 
It is less marked at the angle of the mouth, upon the tongue, etc., 
though it may usually be detected without difficulty. The parch- 
ment form of induration is also met with upon this region in some 
instances. 

The ganglia connected with the seat of the chancre by means of 
the lymphatic vessels take on induration, as in infecting primary 
sores upon other parts of the body ; and, in most cases, they belong- 
either to the anterior or posterior sub-maxillary groups. 

Phagedena is a rare complication of the buccal chancre. A 
single instance was observed at Cullerier's clinique, in which irri- 
tant applications had caused the ulcer to extend until it involved 
one-half of the lower lip and the inferior half of the cheek. 1 

All undoubted cases of primary sore which have as yet been met 
with upon the head or face, have belonged to the infecting species ; 
there can be but little doubt, therefore, that any chancre observed 
upon this region will be followed by secondary manifestations. If, 
however, there be any question as to the nature of the ulcer, the 
administration of mercury should be deferred until its necessity 
becomes apparent. 

1 Buzexet, Du Chancre de la Bouclie, etc., These de Paris, 1858. 



426 LYMPHATIC VESSELS AND GANGLIA. 



CHAPTER III. 

AFFECTIONS OF THE LYMPHATIC VESSELS AND 
GANGLIA ATTENDANT UPON PRIMARY SORES. 

Bubo, derived from the Greek "ftovfav, trie groin," etymologically 
signifies any tumor of the inguinal glands ; and the term is also 
commonly applied to glandular swellings of other parts of the body, 
as the axilla, neck, etc. Many affections, distinct in their nature 
and origin, are thus confounded under a common name, which, 
unless limited by some qualifying epithet, conveys but a very vague 
meaning. It would doubtless be desirable, as proposed by Mon- 
tannier and Maisonneuve, 1 to limit the name to acute inflammation 
of the lymphatic ganglia in the neighborhood of a primary sore, 
and thus exclude glandular enlargement dependent upon scrofula, 
and the specific induration symptomatic of an infecting chancre ; 
but until generally adopted by the profession, this change must be 
regarded in the light of an innovation ; and I shall therefore retain 
the ordinary signification, but so qualify the term, wherever it is 
used, as to render its meaning unmistakable. 

The influence of the virus of a soft chancre upon the ganglia is 
confined to those which are nearest to it in the course of the 
lymphatic circulation ; as, for instance, to the inguinal glands when 
the chancre is situated upon the genital organs, and to those of the 
armpit or axilla when it is seated upon the upper extremity. 2 In 
like manner the immediate effect of the virus of the infecting chancre 
is also confined to the neighboring ganglia. At a later period, to 
be sure, those of the back of the neck and other parts of the body 
often become enlarged, but this change is separated from the former 
by a period of incubation, and belongs to the secondary and not to 
the primary manifestations of syphilis. 

1 Traite Pratique des Mai. Veneriennes, p. 164. 

2 See Hunter's remarks upon this point, Ricord and Hunter on Venereal, 2d ed., 
p. 366. 



SIMPLE BUBO — VIKULENT BUBO. 427 

Buboes are always seated in the superficial and never in the 
deep ganglia. They are of three kinds : the simple, virulent, and 
indurated. I shall also inquire into the nature of the so-called 
" bubon d'emblee" (" non-consecutive or primary bubo"). 

Simple Bubo. — The simple, sympathetic, or inflammatory bubo, 
as it is variously called, is due to common inflammation, and, when 
terminating in suppuration, secretes pus destitute of specific 
properties. It is, therefore, identical in its nature with the frequent 
form of adenitis, which appears in the axilla in consequence of a 
wound upon the finger, and which is supposed to be occasioned 
by extension of the inflammation along the course of a lymphatic 
vessel. That this is the case in some instances is shown by a red 
line upon the surface, extending from the source of irritation to the 
inflamed ganglion. 

A simple bubo may attend a chancroid or gonorrhoea of the 
urethra in the two sexes, and, in rare instances, vaginitis ; but has 
never been known to accompany uncomplicated balanitis. Its occur- 
rence is favored by irritant applications to the seat of the original 
disease, by exercise, coitus, alcoholic stimulants, and especially by 
the strumous diathesis. 

The symptoms of simple adenitis are well known. The patient 
first notices a hard swelling of the gland attended with pain and 
tenderness, which impede and are aggravated by motion. When 
suppuration occurs — which does not necessarily ensue — it is often 
ushered in by a chill followed by more or less fever ; the presence 
of matter is indicated by a soft spot in the midst of the general 
hardness of the tumor, and by fluctuation ; the cellular tissue in the 
neighborhood of the ganglion frequently participates in the inflam- 
mation, and may also be the seat of purulent deposit; the skin 
becomes adherent, thin, and of a livid red color, and opens by a pro- 
cess of ulceration ; after the contents of the abscess are discharged, 
the pain gradually subsides, the power of locomotion returns, and 
the simple wound, under favorable circumstances, speedily heals by 
granulation ; but if the opening be not free, or the patient be affected 
with the strumous diathesis or general cachexia, the pus may 
burrow in various directions and give rise to tedious and trouble- 
some sinuses, extending for several inches beneath the surface. 

Yieulent Bubo. — The virulent bubo receives its name from the 
fact that the pus which it contains is contagious, and will, upon 



428 LYMPHATIC VESSELS AND GANGLIA. 

artificial inoculation, give rise to a soft chancre. It is sometimes 
called " the syphilitic bubo," but this term, if used at all, properly 
belongs to the induration of the ganglia accompanying an infecting 
chancre, and is entirely inapplicable to the bubo under consideration, 
which can only arise from a chancroid. If it be allowable to invent 
an adjective for the occasion, it may appropriately be called the 
chancroidal bubo. 

A virulent bubo may form either at an early or late period of 
the existence of a chancroid. M. Puche reports a case in which it 
first made its appearance three years after the commencement of a 
soft, serpiginous chancre. 1 

A virulent bubo is due to the absorption of virus from the sur- 
face of a chancroid, and its conveyance by means of the lymphatics 
to the ganglion ; here its farther progress is arrested in the intricate 
meshes and minute ramifications of this body, and its presence gives 
rise to inflammation which assumes the specific character of the 
exciting cause. The same power of reproduction is manifested 
which gives to virulent pus its contagious qualities, and the abscess 
which necessarily ensues is filled with inoculable matter. Eesolu- 
tion is as impossible and suppuration as inevitable as if the secre- 
tion of the chancroid had been deposited within the ganglion upon 
the point of a lancet. 

Virulent adenitis is usually situated upon the same side as the 
chancroid, but sometimes upon the opposite, owing to the interlace- 
ment of the lymphatic vessels upon the dorsum of the penis. 
Sometimes both groins are affected, especially when the primary 
sore is situated upon any part in the median line, as the fraenum. 
It is very rare for more than a single gland on one or both sides to 
suppurate specifically ; and hence the virulent bubo is said to be 
"mono-ganglial." Other ganglia in the neighborhood may, how- 
ever, be secondarily affected through sympathy or extension of the 
inflammatory process, but should they suppurate, the pus is not 
inoculable like that of the first ganglion. 

Prior to its spontaneous or artificial opening, the course of a 
virulent is the same as that of a simple bubo, and the student should 
understand that the early symptoms of the two are identical ; though 
the distinction between them is fully justified by the inevitable sup- 
puration and specific properties of the one, and the possible resolu- 
tion and simple character of the other. 

1 Ricord, Lecons sur le Chancre, p. 40. 



VIRULENT BUBO. 429 

The virulent pus is at first confined to the interior of the affected 
ganglion, and does not communicate with the abscess which often 
forms in the surrounding cellular tissue. In this case the pus 
which issues when the integument alone is divided by the knife, is 
innocuous, but if the incision be made to include the ganglion, the 
contents of the latter may be proved to be contagious by artificial 
inoculation. 1 The specific matter from the gland speedily inocu- 
lates the whole surface of the wound and transforms it into an 
inguinal chancroid, presenting the everted and sharply-cut edges, 
and grayish aspect of this species of primary sore, and capable of 
giving rise to other ulcers in the neighborhood by successive 
inoculation. If the chancroid upon the genitals be complicated 
with phagedena, the open bubo generally follows the same course ■ 
and hence arise those extensive and foul ulcerations of the groin 
which are occasionally seen in hospitals, and which are depicted in 
nearly all illustrations of venereal diseases. 

As a general rule, morbid products which undergo absorption do 
not manifest their presence in the lymphatics themselves, probably 
in consequence of the rapidity of their passage, and the chano-es 
which take place in the ganglia where their progress is impeded, 
are the only indications that this system of vessels is affected. In 
conformity with this law, the lymphatics which convey the pus 
from the chancroid to the ganglion generally escape, but in some in- 
stances inoculation takes place and virulent lymphangitis is set up. 
This should be carefully distinguished from the induration of the 
lymphatics observed in cases of the infecting chancre. In both, a 
thickened cord may be felt running along the upper surface of the 
penis ; but in the former it presents the characters of ordinary in- 
flammatory engorgement, usually includes the dorsal vein and artery 
which are united to it by inflammation of the surrounding cellular 
tissue, is attended by considerable heat and pain in the part, and 
the skin over it is swollen and red ; while in the latter, there are no 

1 " Equally instructive examples (that the glands collect hurtful ingredients, 
and thereby afford protection to the body) are afforded by the history of syphilis, 
in which a bubo may for a time become the depository of the poison, so that the rest 
of the economy is affected in a comparatively trifling degree. As Ricord has 
shown, it is precisely in the interior of the real substance of the gland that the 
virulent matter is found, whilst the pus at the circumference of the bubo is free 
from it ; only so far as the parts come into contact with the lymph conveyed from 
the diseased part, do they absorb the virulent matter." (Viechow, Cellular Pathol- 
ogy, p. 187.) 



430 LYMPHATIC VESSELS AND GANGLIA. 

symptoms of acute inflammation, and the indurated lymphatic may 
readily be isolated from the neighboring bloodvessels. 1 Virulent 
lymphangitis, like a virulent bubo, necessarily terminates in sup- 
puration ; abscesses form in the course of the vessel either upon 
the penis or pubes, and, when open, are in reality chancroids. 

Indueated Bubo. — This affection is only met with in connection 
with an infecting chancre, of which it is as necessary an attendant, 
and affords as valuable an indication as the induration of the base 
of the sore. Of 120 cases of syphilitic erythema, Bassereau found 
that in 116 indurated buboes had accompanied the chancre, only 
one of which had suppurated ; in three alone had there been no 
appreciable changes in the inguinal ganglia. 

The indurated bubo, unlike either of the preceding, is always 
developed at an early period — usually during the first week, and 
invariably within the first three weeks of the existence of the 
ulcer — and is contemporaneous with the induration of its base, or 
follows it almost immediately. 

The simple and virulent buboes are mono-ganglial, the indu- 
rated poly-ganglial. All the superficial ganglia in one, and gen- 
erally in both groins, become enlarged, and attain the size of a 
filbert or almond. One is frequently found to be more devel- 
oped than the others, which surround it like satellites. This 
change takes place without any symptoms of acute inflammation, 
and so insidiously that the patient may be entirely ignorant of 
it, and deny its existence; but the surgeon, whose suspicion has 
already been excited by the induration of the primary sore, on 
examining the groin, finds a "pleiad" of small tumors, of a cartilag- 
inous hardness, and freely movable upon each other and the sur- 
rounding tissues. When firm pressure is made upon them, the 
patient sometimes complains of slight tenderness but not of severe 
pain. They preserve their indolent character throughout their 
whole course, and do not become inflamed or suppurate unless 
under the influence of some aggravating cause, as violence, a stru- 
mous diathesis, general cachexia, or the coexistence of a chancroid 
or urethritis; and, except in the case of a chancroid, the pus is 
never inoculable. 

Induration of the ganglia and induration of the base of an infect- 

1 Bassekeau, op. cit., p. 160. 



INDTJKATED BUBO. 431 

ing chancre are in their nature and signification one ; but, as else- 
where remarked, the first is perhaps the more constant and per- 
sistent, and, therefore, the more valuable symptom. When the 
latter is imperfectly developed or obscured by common inflam- 
mation, reference may be made to the former, which will rarely 
fail to afford the desired information; after the latter has disap- 
peared, the former often persists for months, as an index, that upon 
some part of the superficies the lymphatics of which rendezvous at 
these ganglia, there has been a primary sore which has infected the 
constitution ; and thus it determines not only the existence but the 
approximate seat of a chancre, and may afford invaluable aid in 
unravelling the history of venereal cases. For instance, induration 
of the inguinal ganglia points to the genital organs, including the 
internal surface of the urethra, and to the hypogastric region ; that 
of the external group near the anterior superior spine of the ilium 
to the anus ; that of the submaxillary glands to the lips, mouth, 
and tongue ; that of the axillary ganglia or those about the elbow 
to the hand or arm ; that of the preauricular ganglion to the eye- 
lid and its neighborhood; and so each region has its recording 
index. 

From induration of the inguinal ganglia, I have repeatedly been 
able to satisfy myself of the previous existence of a chancre in op- 
position to the asseverations of patients, and even when no cicatrix 
or specific induration could be found upon the genital organs. For 
instance, in the spring and summer of last year, a young man had 
two attacks of what was apparently simple gonorrhoea. In the 
autumn he applied to me with syphilitic iritis, alopecia, acne capitis, 
and post-cervical engorgement, and there could be no doubt that 
he had had a chancre upon the genitals, although he was quite 
unconscious of the fact, since each groin presented the charac- 
teristic indurated pleiacl. One of his attacks of gonorrhoea was 
probably complicated with a urethral chancre. 

Ricord relates the following case : l — 

" Two or three years ago, one of our most prominent young physicians 
came with a frightened air to my office, when the following conversation 
ensued : ' Until now I had faith in your doctrines, but I find them at fault, 
and in my own person. It is too bad. What is this V (removing his 
clothes and showing me his breast and back). I examine him and 
reply :— 

1 Lettres sur la Syphilis, 2d ed., p. 45. 



432 LYMPHATIC VESSELS AND GANGLIA. 

" ' A fine syphilitic roseola.' 

" ' Syphilitic, did you say ? Are you sure V 

tl ' Perfectly so.' 

" « Yery well ! You condemn yourself. I have never in my life had 
any venereal symptom but a gonorrhoea, and that was twelve years 
ago.' 

" I examine him from head to foot, and say to him :— 

" ' My friend, you have recently had a chancre on your right hand, 
which was situated neither upon the thumb nor index, but upon one of 
the remaining fingers.' 



You are jokin 



" ' Not at all ; you have a bubo at the present moment;' and I place 
his finger upon a ganglion still engorged near the elbow-joint. After 
thinking a moment, he then told me that a few months before, while treat- 
ing a woman with chancre, an ulcer appeared on the middle finger of his 
right hand, to which he paid but little attention, and which had soon 
healed. ' This,' said I, 'is the source of your roseola; act accordingly.' " 

I do not recollect a single instance in my own practice, which 
ultimately proved to be one of the infecting chancre, in which 
induration of the neighboring ganglia was wanting ; yet Basserean's 
statistics above referred to would appear to show that this may 
occasionally happen ; though it should be observed that many of 
this surgeon's patients were not seen until a month or two after 
contagion, by which time this symptom may possibly have disap- 
peared. Yet I think that the absence of induration of the base of 
an infecting chancre and of its attendant bubo may, in rare instances, 
be admitted, without materially detracting from the value set upon 
their diagnostic and prognostic indications ; for why should abso- 
lute constancy be expected in syphilitic symptoms any more than 
in those of other diseases, and in the whole range of pathology it 
would be difficult to find two which are more uniformly present 
than these. Induration does not constitute the essence of syphilis, 
which lies in the virus ; neither the base of the sore nor the ganglia 
are indurated when an infecting chancre is implanted upon a sys- 
tem already contaminated with syphilis, yet the poison remains the 
same. 1 

The only affection liable to be confounded with an indurated 
bubo is strumous enlargement. of the ganglia, and I have met with 
a number of cases, in which the diagnosis remained for a while in 

1 Vide p. 342. 



INDURATED BUBO. 433 

doubt, owing to ignorance of the condition of the glands before 
contagion. In persons of a strumous diathesis who can give no 
reliable account of their previous history, this difficulty must some- 
times arise. 

It is perhaps unnecessary to remind the reader that an indurated 
bubo is not to be looked for in old cases of syphilis of several years' 
duration. Like the induration of the chancre, it disappears, even 
without treatment, after a variable period, although somewhat more 
persistent than the latter. 

The value of suppuration in a bubo as an element of diagnosis 
is a question of considerable practical importance. A patient with 
general symptoms of a doubtful character seeks advice of a sur- 
geon, who learns that several years ago he had a primary sore, but 
can obtain no accurate description of its symptoms. On farther 
inquiry he also ascertains that there was tumefaction of the glands 
in the groin, and the patient rarely fails to remember whether they 
suppurated or not — a fact which may also be determined in most 
cases by the presence or absence of a cicatrix. What light will 
this investigation throw upon the nature of the chancre ? If the 
description above given of the different kinds of bubo be correct, 
the fact that suppuration took place will favor but will not absolutely 
prove the supposition that the sore -was a chancroid. It is a general 
but not invariable rule that constitutional syphilis does not follow an 
open bubo. 

Indolence is one of the chief characteristics of an indurated bubo, 
but to deny that suppuration ever takes place, as some authors 
have done, is to assert that induration protects the ganglia from 
every cause of acute inflammation, which is evidently absurd. If 
the primary sore be of the mixed variety, or if a chancroid and a 
chancre coexist upon the genitals, a virulent bubo and constitu- 
tional infection may both follow. A remarkable instance of this 
kind has already been related upon page 382. 

Again, irritant applications to the chancre, external violence, 
alcoholic stimulants, excessive coitus, gonorrhoea, or fatigue, may 
excite common inflammation, terminating in an abscess, of ganglia, 
indurated in consequence of constitutional infection ; but the most 
fruitful source is the strumous diathesis or general debility. The 
following case will illustrate the fact that suppuration may be due 
to several causes combined, and cannot always be ascribed to the 
influence of the virus alone upon the ganglia. 
28 



434: 



LYMPHATIC VESSELS AND GANGLIA. 



B. belonged to a strumous family. His sister, aged IT, had been 
afflicted with an aggravated form of chronic eczema since early infancy. 
His brother, after hardship and exposure upon a wreck, was confined to 
his bed for six months with suppuration of the inguinal glands. B., who 
had always enjoyed good health, contracted a chancre in June, 1859, fol- 
lowed by an indurated bubo. Syphilitic erythema appeared in September, 
when the bubo, which until then had been indolent, became inflamed, 
suppurated, and remained open six weeks. The constitutional disease 
proved to be very obstinate, and he was still under treatment in • July, 
1860, when, after violent exercise at leap-frog, another abscess formed in 
the same groin. 

It will be noticed in this case, that the inguinal glands remained 
in a quiescent state for nearly three months after the healing of the 
chancre, and their suppuration at the end of this time can only be 
ascribed to the strumous diathesis of the patient, and also, in a 
measure, to the febrile excitement preceding the syphilitic eruption. 

Statistics collected by various observers concur in showing the 
rarity, but yet the possibility of a suppurating bubo attending a 
chancre followed by secondary symptoms. The following table 
which I have compiled from Bassereau, exhibits : 1st. The number 
of cases of constitutional syphilis under observation, which were 
preceded by buboes ; 2d. The number of buboes which suppurated, 
and 3d. The form of eruption which subsequently appeared : — 



Whole Number. 


Suppurated. 


Form of Eruption - . 


117 . 


. 1 


Erythematous. 


42 . 


.5 


Papular. 


108 . 


. 1 


Mucous patches 


12 . 


. 1 


Vesicular. 


54 . 


.. . 4 


Pustular. 


50 . 


. 4 


Tubercular. 


Total 383 


16 





Thus in 383 cases of infecting chancre attended by an affection 
of the ganglia and followed by secondary symptoms, there were 
only sixteen suppurating buboes. 

Fournier states that in the large number of indurated chancres 
treated by Eicord, at the Hopital du Midi, in the year 1856, there 
were only three which were accompanied by suppurating buboes. 

Mr. Henry Lee, in an analysis of 1409 cases of venereal disease, 
"excluding simple gonorrhoea," recorded in the books of Lock 
Hospital, London, found ninety-eight cases of secondary symptoms, 
complicated with suppurating bubo, but in all, with the exception 



INDUKATED BUBO. 435 

of six, there was reason to believe that the latter affection was due 
to a different contagion from the one which produced the former, 
or to causes independent of the syphilitic virus. 1 

Bassereau reviews this subject in so clear a light, that I shall 
quote his remarks: "There is a fact which is not recognized by 
most writers on syphilis, and of which many practitioners are igno- 
rant; I refer to the rarity of suppurating buboes attending those 
chancres which precede general syphilis. The inverse proposition, 
viz., that general syphilis is rare after chancres attended by suppu- 
rating buboes, is equally true, and as generally unknown, although 
of great practical importance. It is not to be inferred, however, that 
every person who has a chancre and indolent ganglionary engorge- 
ment must necessarily have general syphilis ; nor that the appear- 
ance of suppuration in a bubo is a guarantee that the patient will 
be free from all constitutional manifestations ; since very many in- 
flamed ganglia, which do not suppurate, are never followed by 
infection of the system, and a few suppurating buboes are succeeded 
by general syphilis. But though suppuration and indolence are 
not symptoms of absolute value, they at least furnish a strong pre- 
sumption as to the future, and hence afford diagnostic and thera- 
peutic indications of great importance. Even many years after 
contagion, data with regard to the course pursued by any glandular 
engorgement which accompanied the primary sore, will assist us in 
determining the character of symptoms, the nature of which appears 
doubtful. Suppose, for instance, that we wish to know whether a 
cutaneous eruption or ostitis is syphilitic ; if we find as antecedents 
a chancre and a suppurating bubo, there is little probability of its 
specific origin ; and though mercury is not absolutely contra-indi- 
cated, prudence will lead us not to employ it longer than is neces- 
sary to test its effect. 

"The early writers on syphilis did not include suppurating 
buboes among the symptoms which preceded those general erup- 
tions which then bore the name of ' the French disease ;' and when 
the efficacy of mercury in the treatment of the new disease was 
recognized, they did not administer it indiscriminately to all per- 
sons affected with ulcers upon the genital organs and with buboes, 
without distinguishing between the different forms of these symp- 

1 On the Non-mercurial Treatment of Certain Forms of Syphilitic Disease ; 
Analysis of 1400 cases. Association Med. Journal, Dec. 7, 1855. 



436 LYMPHATIC VESSELS AND GANGLIA. 

toms. This fact may be established by reading their writings. 
The first half of the sixteenth century had not, however, passed, 
before they began to depart from these sound doctrines ; but sup- 
purating buboes had no sooner been confounded with the symptoms 
of 'the French disease,' than physicians noticed that they appar- 
ently afforded protection against general manifestations. Consult 
with regard to this point Nicholas Massa, Mathiolus, Antonius 
Lecoq, and Botal; they all call attention to this fact, and "William 
Eondelet comes still nearer to the truth when he says that buboes 
which undergo resolution, and those which are indurated and show 
no tendency to suppurate, are certain indications that constitutional 
syphilis is imminent : ' Si qui dolores patiantur, prascesseritque ex- 
ulceratio in mentula intra vel extra et bubones venerei qui non 
proffuxerint sed retrocesserint vel indurati sint, eos morbo gallico 
laborare certo et intrepide, etiamsi negent, afnrmare possumus.' " 

Induration of the Lymphatics. — As both the simple and virulent 
bubo have their occasional attendants in simple and virulent lym- 
phangitis, so has the indurated bubo its accompanying induration 
of the lymphatics, a more constant attendant, though not invariably 
present, than either of the former. 

Specific engorgement of the lymphatics is dependent upon 
changes in the walls of these vessels identical with those which 
occasion induration of the base of the chancre and of the ganglia, 
and is characterized by the same three important symptoms, viz., 
induration, absence of inflammation, and persistency. 

The indurated vessel feels like a hard cord running from the 
neighborhood of the chancre towards the pubes along the upper 
surface of the penis in the course of the dorsal vein and artery, or, 
in a few instances, occupies the side of this organ. It is generally 
single, but sometimes multiple ; of the size of a crow or goose- 
quill; in some cases of uniform diameter, when it communicates 
to the fingers a sensation like that of the vas deferens, while in 
others it is swollen at regular intervals like a necklace, or is, as 
botanists would say, moniliform. The distal extremity arises in 
the induration surrounding the chancre, and the cord can generally 
be traced for two or three inches towards the pubes, sometimes to 
the base of this prominence, but rarely as far as the indurated 
ganglia in the groin. 

Induration of the lymphatics is most frequently observed upon 
the penis, but is not limited to this organ. Bassereau relates a 



NON-CONSECUTIVE BUBO. 437 

case of infecting chancre upon the cheek, in which a hard cord 
could be traced from the indurated base of the sore to an indurated 
bubo beneath the angle of the jaw. 

Induration of the lymphatics appears about the same time and in 
the same manner as that of the base of the chancre, and the two 
generally correspond in degree of development. As already stated, 
the former is less constant than the latter, but if sought for may be 
found in a large proportion of cases. 

Induration of the lymphatics usually undergoes resolution about 
the same time as that of the base of the sore ; but in a few rare 
instances it becomes inflamed and terminates in suppuration, when 
fistulous openings may form along the course of the vessel. Bas- 
sereau met with three cases in which the induration of the chancre 
took on inflammatory action and was transformed into a phlegmo- 
nous tumor, the cavity of which was found to communicate with 
the interior of an hypertrophied lymphatic, through which a probe 
could be passed up to the pubes. In one instance he was able to 
make a post-mortem examination, the patient having died of an 
intercurrent acute disease. The dorsal vein and artery were found 
to be intact, and the fistulous canal evidently consisted of an hyper- 
trophied lymphatic with hard and thickened walls, which could be 
traced from the induration of the chancre to the right inguinal 
ganglia. 

Induration of the lymphatics may readily be distinguished with 
care from the dorsal vein and artery. It is more liable to be con- 
founded with simple or virulent lymphangitis. The diagnostic 
symptoms have already been given when describing the latter. 

This symptom of an infecting chancre has the same prognostic 
signification as the induration of the base of the sore and the in- 
guinal ganglia, and denotes that the constitution is already infected 
and that general syphilis will soon make its appearance. 

"Non-consecutive Bubo," or "Bubon d'Emblee." — These 
terms are applied to a class of cases in which the inguinal ganglia 
become inflamed and suppurate after coitus, without our being 
able to detect the presence of a chancre, and with regard to the 
character of which a great diversity of opinion has been expressed. 
The only surgeon, so far as I am aware, who has investigated the 
symptoms and nature of this affection, with the light afforded by 



438 LYMPHATIC VESSELS AND GANGLIA. 

the more recent discoveries in venereal, is Diday, who describes 
the symptoms of the bubon d'emblee as follows r 1 — 

1. A long period of incubation, which is usually of about three 
weeks' duration. 

2. A few days before the appearance of the bubo ; the patient 
suffers from general disturbance of the system, inability to sleep, 
heat and dryness of the skin, irregular chills, lassitude, loss of 
appetite, and pain in the lumbar region. These symptoms pre- 
cede rather than follow the evolution of the bubo, do not correspond 
with it in intensity, and diminish as it progresses. 

3. The inflammation is always subacute. The tumor is slow in 
forming ; the pain and sensibility are slight ; and if suppuration 
take place, the skin does not become reddened nor matter form in 
the surrounding cellular tissue, as almost invariably occurs in 
virulent adenitis. 

4. It is of long duration, and under the most favorable circum- 
stances generally persists for at least a month. 

5. It suppurates in about one case out of every four ; but the 
opening of the abscess is never transformed into a chancre, and the pus 
can never be artificially inoculated. 

6. Constitutional syphilis never follows when this has been the only 
venereal symptom. 

Diday states that clinical observation compels him to admit the 
existence of a bubo not preceded by a chancre and presenting the 
above characters ; that so far he is sustained by facts, the explana- 
tion of which is, however, quite another matter, and one which he 
approaches with much hesitation. He yet ventures to suggest a 
theory to account for their origin by supposing that the virus of 
the chancroid may, under certain conditions, reach the ganglia 
through the absorbents without giving rise to an ulcer at its point 
of entrance, but that it is so modified by imbibition that it loses 
its specific properties, acts only as a common irritant, and does not 
occasion a virulent bubo. 

Ricord explains the same cases on the ground, either that " their 
appearance after coitus is a mere coincidence and that they are due 
to other causes, or that they are occasioned by sympathetic reac- 
tion consequent upon irritation of the extremities of the absorbents 
during coitus, as may occur after any non-specific excitation of the 

1 Nouvelles Doctrines sur la Syphilis, p. 186. 



NON-CONSECUTIVE BUBO. 439 

part." To this Diclay objects, that buboes do not follow a much 
greater degree of irritation than is produced by sexual intercourse; 
that, for instance, they are not observed after excision or cauteriza- 
tion of vegetations and haemorrhoids, operations for phymosis, am- 
putation of the penis, etc.; and hence that it is unreasonable to 
suppose that they may arise from mere coitus without contagion. 

I can say for my own part that I have met with several cases of 
bubo presenting in the main the same combination of symptoms as 
described by Diday, and in which, upon the most careful examina- 
tion, no chancre could be discovered. I have particularly noticed 
the subacute character and the slow development of the tumor, and 
the absence of subsequent symptoms of constitutional sj^philis. 
Private practice has not afforded me the opportunity to test the 
nature of the contained pus by artificial inoculation, but the open- 
ing of the abscess has never assumed a chancrous appearance ; and 
the freedom from constitutional infection has been confirmed by 
long-continued observation. But I have seen no reason whatever 
to believe that these cases were in any way connected with either 
species of chancrous virus, and I regard Diclay's theory to account 
for their origin as fanciful and untenable. I believe that they are the 
effect of irritation or excessive exercise of the genital organs during 
coitus, aided frequently by a strumous diathesis, or other accessory 
causes. The influence of muscular fatigue and local irritation upon 
distant organs is difficult of explanation but is often observed in 
other parts of the body. Diclay's objection to this view is readily 
answered by propounding two questions, viz : Which is the more 
likely to excite axillary adenitis, amputation of the arm, or a scratch 
upon the finger ; and will an operation for phymosis probably ag- 
gravate an inguinal bubo more than a long walk or repeated acts 
of coitus? Eegarding this affection, therefore, as entirely inde- 
pendent of contagion, I deem it unfortunate that it has received the 
name of bubo, which is commonly applied to diseases of the ganglia 
dependent upon the virus either of the chancroid or true chancre, 
and which, therefore, in the present instance, is apt to lead to an 
erroneous conclusion. The existence of a bubon d'emblee, secreting 
inoculable pus and capable of infecting the constitution, is entirely 
inconsistent with our present knowledge of venereal diseases, and 
cannot now, as formerly, be admitted. The reported cases of this 
character are very far from being conclusive. 



440 LYMPHATIC VESSELS AND GANGLIA. 

Teeatment of Buboes. — In respect to treatment, bnboes may 
be divided into two classes — 1. Acute inflammation of the ganglia 
prone to terminate in suppuration, and requiring local treatment ; 
2. Indurated buboes, free from inflammation, and demanding only 
general treatment. 

The first-mentioned division includes both the simple and viru- 
lent bubo, and also those exceptional cases of indurated buboes in 
which inflammation is set up by some cause independent of the 
syphilitic virus. In all these, inflammation, though varying greatly 
in intensity in different cases, is the prominent symptom, requiring 
attention ; and to subdue this, if possible, and avert suppuration, 
and to hasten cicatrization when an abscess forms, are the objects 
of treatment. 

When the bubo is virulent and specific pus is imprisoned within 
the ganglion, all attempts to effect resolution will certainly fail ; but 
as this species cannot, at an early period, be distinguished from a 
simple bubo — although the presence of a chancroid upon the 
genitals may lead us to suspect it — we cannot in practice discrimi- 
nate these cases, and must treat all inflammatory buboes as if 
dispersion were possible. This happy result is not, indeed, attained 
in the majority of cases, but inaction will never satisfy the patient, 
and the success of remedies in a few instances will amply compen- 
sate for their employment in all; since a suppurating bubo is a 
source of considerable pain and great annoyance, generally necessi- 
tates confinement in bed for several days at least, exposes the 
patient to detection, and leaves an indelible cicatrix. The idea 
formerly entertained that danger would result from the " repulse of 
matter" if buboes were dispersed, is now known to be without 
foundation. 

The means employed to effect resolution are an antiphlogistic 
regimen (rest and low diet), cathartics, local depletion, counter- 
irritants, and compression. 

General Treatment. — General remedies are not always required. 
When the inflammation is subacute, local applications may be relied 
upon from the first. 

Eest is of course of the first importance ; and the more absolute, 
the better. It would appear that common sense would suggest this 
to every one with a commencing bubo, but if the surgeon rely upon 
the patient's intelligence alone, he will in most cases be disappointed, 
and will find that the swelling has been aggravated by a long walk, 



COUNTER-IRRITANTS. 441 

or by what is equally detrimental, the standing posture. Rest upon 
the back should in all cases be secured, if possible. An active 
cathartic at the outset will rarely be amiss, and an evacuation from 
the bowels should be obtained daily. If the patient be of full 
habit, his diet should be low; but when the system is already 
depressed or cachectic, strict abstinence will favor suppuration, and 
should be avoided. 

Similar rules should govern the use of local depletion, the' benefit 
from which, however, is so uncertain as scarcely to compensate for 
its inconvenience ; yet when the patient is plethoric, and the local 
symptoms acute, from six to a dozen leeches may be applied near 
(not upon) the tumor, and the bleeding be promoted by immersion 
in a hot bath ; but leeches should never be used when an abscess 
has formed and is upon the point of opening, lest their bites be 
inoculated and transformed into chancroids. The administration of 
a solution of Epsom salts and tartar emetic may often be advan- 
tageously substituted for abstraction of blood in any manner. 

No benefit can at this period be expected from specific remedies. 
Mercury is uncalled for, since the inflammation is not dependent 
upon the action of the virus of true syphilis. I have frequently 
employed iodide of potassium, but never with perceptible effect 
unless in strumous subjects. 

The large number of local applications recommended in the 
early treatment of buboes proves how little dependence can be 
placed upon any of them. Nearly all of them act as counter-irri- 
tants, or aim to produce absorption and resolution by compression. 
To this remark ice is an exception, which if applied to a bubo at 
its very commencement before acute inflammation is set up will 
sometimes discuss it. 

Counter-irritants. — One of the best counter-irritants is the strong 
tincture of iodine. I do not attribute its beneficial action to any 
special power of inducing absorption, but rather to the inflamma- 
tion of the skin which it excites. The same may be said of the 
following ointment, which I am also in the habit of using : — 

R. Potassii iodidi [)j. 

Iodinii gr. v. 

Unguenti hydrargyri §j. 
M. 

Either of these preparations may be applied twice a day until as 
much inflammation is induced as the patient can well bear, when 
the application must be less frequent. 



442 LYMPHATIC VESSELS AND GANGLIA. 

A strong solution or the solid crayon of nitrate of silver is 
another excellent counter-irritant highly recommended by Mr. 
Henry Thompson/ whose paper on the subject first induced me to 
try it. The strength of the solution is three drachms of the nitrate 
of silver to the ounce of water with the addition of twenty min- 
ims of strong nitric acid. This should be freely applied to the 
whole surface of the tumor and be repeated as soon as the eschar 
comes away; or the solid nitrate of silver may be employed by 
first moistening the part with water and then rubbing the crayon 
for a few minutes upon it. 

A blister may be employed for the same purpose and the vesi- 
cated surface be dressed with various irritant or resolvent oint- 
ments. When the acute symptoms have somewhat subsided, or 
at the outset of virulent buboes, Eicord recommends that the blister 
should be dressed twice a day with half a drachm of strong mer- 
curial ointment, and be covered with a rye-meal poultice which 
should be changed three or four times in the twenty-four hours. 
A caustic solution of the bichloride of mercury, proposed by MM. 
Malapert and Keynaud for the treatment of buboes after suppura- 
tion has taken place, has also been employed by some surgeons for 
the purpose of inducing resolution. 

A few years since a favorite mode of treatment of subacute 
buboes in the French hospitals was by means of "cauterisation 
ponctuee," or the rapid application of a pointed iron heated to a 
white heat to numerous points over the tumor. This method was 
tried at my suggestion at Bellevue Hospital in this city with very 
satisfactory results. The dread rather than the pain of the appli- 
cation, which does not exceed that produced by many caustics, 
interferes with its adoption in private practice. • 

Compression. — Compression is another means employed to induce 
resolution of buboes, and is said to have been suggested by the 
observation that these tumors do not occur wherever a truss is 
worn. The most ready method of applying pressure is by means 
of compressed sponge and a spica bandage, and the application of 
hot water to cause the sponge to swell. An Interne of the Hopital 
du Midi has invented a truss or pad for the same purpose, consist- 
ing of a rounded piece of wood covered with leather, and provided 
with straps to pass round the waist and thigh. This may be ob- 

1 London Lancet, Am. ed., June, 1855, p. 536. 



METHODS OF OPENING BUBOES. 443 

tained at most instrument makers, and is very convenient and 
serviceable. It is generally called "Ricord's pad for buboes." 
Reynaud 1 combines heat and pressure by heating the half of a 
common brick, the edges of which have been chipped off, wrapping 
it in a napkin, laying it upon the bubo, and changing it at the end 
of three or four hours, by which time it becomes cool. 

The application of collodion, which, by its power of contraction, 
exerts pressure upon the tumor, has been recommended by Dr. 
J. H. Clairborne and others. 

Methods of Opening Buboes. — So soon as matter can be detected, 
and it is evident that resolution is impossible, the abscess should 
at once be opened. Delay will allow the pus to collect and under- 
mine the skin, which, becoming thin and deprived of its vascular 
supply, will be destroyed to a greater • or less extent, thereby in- 
creasing the difficulty of cicatrization and adding to the dimensions 
of the unsightly scar. 

The knife is in most cases preferable to caustic for this pur- 
pose. The extent and number of incisions to be made have been 
the subject of much discussion, and have called forth a great diver- 
sity of opinions. The chief question has been between a single 
free opening and a number of small punctures. The object pro- 
posed in these two methods is different. In the first, it is intended 
to transform the abscess into an open wound which will heal by 
granulation from the bottom ; in the second, which is the less pain- 
ful method, the design is to simply evacuate the contents of the 
swelling and secure adhesion of its walls, and thus expedite the 
cure and avoid the formation of a cicatrix. These results are indeed 
highly desirable provided they can be attained, but my own expe- 
rience has led me in most cases to give a decided preference to the 
former course ; since in numerous trials with multiple punctures, 
the matter, not finding free exit, has burrowed in various directions, 
and it has become necessary to resort to a free incision before cica- 
trization would take place. 

My manner of proceeding is as follows. The hair should be 
thoroughly shaved from the surrounding parts to facilitate the 
after-dressing and promote cleanliness. If the patient be nervous, 
I administer ether so as thoroughly to explore the abscess without 
interruption. Entering the point of the knife at the most dependent 

1 Traite des Maladies Veneriennes, p. 76. 



444 LYMPHATIC VESSELS AND GANGLIA. 

part of the tumor, I carry the incision upwards parallel with the 
median line of the body to the full extent of the cavity. An in- 
cision in this direction is preferable to one in the course of the 
inguinal fold, since its edges are separated while those of the latter 
are approximated, by flexure of the thigh. Exposure to the air 
generally arrests the hemorrhage in a few moments, when I care- 
fully examine the walls of the cavity for sinuses, and if any are 
found extending more than half an inch beneath the surface, I slit 
them up with a probe-pointed bistoury. Glands nearly isolated by 
the suppuration of the surrounding cellular tissue, and attached 
only by a small base or pedicle, are often found projecting into the 
cavity; and having been taught by experience that the wound 
does not commonly heal until these are cast off by a slow process 
of ulceration, I remove them with scissors or tear them out with 
the fingers when this can be done without much violence. If left, 
their dark sloughy surface is perceptible for a long time, and they 
doubtless prolong the process of cicatrization. 

The hemorrhage from this operation is seldom so severe that it 
may not be arrested by exposure to the air, ice, or pressure ; but 
should it be profuse, or continued even in a small quantity, the 
bleeding vessel must be secured. I once saw a patient in whom a 
bubo had been opened, and who was completely blanched by a 
slight oozing of blood which had been allowed to go on for a 
number of days, beneath the coagulum which formed upon the 
surface. 

Scraped lint, either dry or moistened in a mixture of laudanum 
and water, is now introduced into every recess of the cavity, paying 
particular attention to any short sinuses which it was not thought 
necessary to lay open with the knife, and a poultice or water- 
dressing applied. The pain and difficulty of motion which proba- 
bly diminished on the first formation of matter, again increase for 
a few days, but are not severe if the patient keep quiet on his back. 
The first dressing, which becomes glued to the wound by coagu- 
lated blood, is loosened about the third day by the free secretion of 
matter, and should be removed, having first applied a hot poultice 
for a few hours. The subsequent dressings may consist of lint 
smeared with simple or medicated cerate, or moistened with any 
of the lotions recommended in the treatment of chancres (as nitric 
acid and water, aromatic wine, Labarraque's solution, or the potas- 
sio-tartrate of iron), and will require to be changed twice a day. 



METHODS OF OPENING BUBOES. 445 

The cavity should from time to time be examined, and any bur- 
rowing sinuses that may be found be slit up with the knife ; those 
of small extent, however, may be made to close by filling them 
carefully with lint at each dressing. The rapidity with which the 
wound contracts by granulations from the bottom and the approxi- 
mation of its sides, is often astonishing, and but from two to four 
weeks are generally required for complete cicatrization to take 
place, during which time it is desirable that the patient should be 
confined to his room. 

But though I cannot subscribe to the high encomiums bestowed 
upon multiple incisions, and think that they are inapplicable to the 
treatment of most buboes, yet I believe that they may be used with 
advantage in a few cases in which the abscess is superficial, and the 
skin over a considerable surface so thin and of such low vitality 
that a free incision would probably result in its total disorganization. 
In such instances, a number of punctures with a bistoury or a 
grooved needle may be made around the margin of the tumor (as 
recommended by Yidal) rather than towards its centre, and the 
contents be allowed to drain away. Continued pressure should be 
applied after the lapse of twenty-four hours by means of compresses 
and a spica bandage, in order to prevent any farther collection of 
matter and secure adhesion of the walls. Even when these objects 
are not attained, the abscess will have time to contract, and a subse- 
quent free incision may, if necessary, be made with less destruction 
of the integument. 

Langston Parker's favorite treatment is as follows: "When a 
bubo is ready to be opened, we should not suffer the skin to become 
too thin, but make several very small punctures over its thinnest 
part with a grooved needle, perhaps six, eight, or ten ; through these 
the matter will ooze out till the cavity of the abscess is empty. 
Through one of the punctures the point of a very small glass syringe 
may be introduced, and a very weak solution of the sulphate of zinc 
injected, in the proportion of two or three grains to the half-pint of 
water. When the abscess is quite empty, place over it a large 
compress of lint, and use moderately tight pressure by means of a 
roller. In many instances, if we can keep the patient quiet for 
twenty -four hours, we get either partial or total adhesion of the 
sides of the bubo, and a speedy cure will be the result ; in other 
instances this may not be the case, but by the daily use of the 
injection through one of the punctures, which should be kept open 



446 LYMPHATIC VESSELS AND GANGLIA. 

for that purpose, we succeed in a few days, in almost every case, in 
effecting a cure." 1 I wish that I were able to confirm the above 
praise of this method to its full extent. 

Eoux (de Toulon) and Marchal (de Calvi) have proposed to inject 
buboes immediately after opening them with a mixture of one part 
of tincture of iodine to three or four of water. Langston Parker 
sometimes employs a solution of iodine and iodide of potassium, as 
follows : — 

P^. Iodinii gr. iv. 

Potassii iodidi gr. viij. 

Aquae ^ viij. 
M. 

A filiform seton recommended by Bonnafont, and also by Mr. 
Parker, was reported against by a committee of the Soc. de Med. 
de Paris, in 1859. 

The use of caustics in opening buboes has been advised by 
several authors, but finds few advocates at the present day. 

The method of MM. Malapert 2 and Eeynaud, 3 which acquired 
some notoriety for a time, and was extensively used at the Emi- 
grants' Hospital, Deer Island, Boston, when I was a student of 
medicine, consists in the application of a blister over the tumor, 
and of a pledget of lint soaked in a solution of corrosive sublimate 
(gr. xv to 3j of water) to the vesicated surface previously freed 
from all secretion of serum. The caustic is allowed to remain for 
two hours, or until a superficial eschar is formed, when a large 
poultice is applied. The authors of this method claim that as the 
eschar is detached, the contents of the abscess ooze out through 
minute openings in the integument, the whole substance of which is 
not destroyed, and that the walls of the cavity are so stimulated and 
modified by the caustic that they rapidly contract and adhere. As 
stated upon a previous page, this method, although designed by its 
authors solely for the treatment of buboes after suppuration has 
taken place, has been applied by others for the purpose of effecting 
resolution. The excessive pain attending the application is not 
counterbalanced by any advantage over milder methods. 

Treatment of Difficult Cases. — Unfortunately all buboes do not heal 
so readily as the reader might infer from the preceding remarks, 

1 The Modern Treatment of Syphilitic Diseases, Phil., 1854, p. 148. 

2 Arch. Gen. de Med., March, 1832. 

3 Traite des Maladies Veneriennes, p. 70. 



TKEATMENT OF DIFFICULT CASES. 447 

which are intended to apply to the more favorable cases consti- 
tuting doubtless the majority. Persistent buboes may be divided 
into two classes: 1st. Virulent buboes which take on phagedenic 
action and pursue a similar course to phagedenic chancres upon 
the genitals, and which may extend to a considerable distance 
beyond the inguinal region, giving rise to large open sores ; and, 
2d. Those which are maintained, not by the presence of the chan- 
croidal virus as in the former class, but by some morbid diathesis 
or general cachexia, and which are generally limited to the groin, 
where they burrow in various directions beneath the surface, with- 
out causing extensive ulceration of the integument. 

The treatment of buboes belonging to the first class is the 
same as that of phagedenic chancres, for which I would refer the 
reader to the preceding chapter. At present I would simply recall 
to mind the danger of the internal use of mercury or its topical 
application to the sore in the form of ointment, etc., and to the 
benefit to be derived from nourishing diet, fresh air, tonics (es- 
pecially the potassio-tartrate of iron), and opium internally ; and 
locally from cleanliness, deep cauterization with nitric acid, Vienna 
paste, or the actual cautery, and suitable lotions and dressings. 

Cases belonging to the second class are met with in persons in 
whom the glandular swelling has been allowed to go on unchecked, 
or whose general condition or neglect to comply with the surgeon's 
directions has rendered treatment of no avail; and they are es- 
pecially frequent in patients of a strumous habit and in those who 
have been debilitated by intemperance, an irregular course of life, 
antecedent diseases, want, or other causes. 

To this class belong most of the so-called "constitutional buboes," 
occurring in persons who are really laboring under the syphilitic 
diathesis, but which are not, strictly speaking, to be regarded as 
syphilitic symptoms, since syphilis has merely acted like any other 
depressing influence in predisposing to a low form of inflammation 
and suppuration. Instances of this kind are frequent ; advice is 
sought by a patient who evidently has constitutional syphilis and 
who has perhaps arrived at the tertiary stage ; his general condition 
is very low ; he complains of nocturnal pains, and exhibits a patch 
of rupia upon the arm, and also a large, oval, firm and projecting 
tumor in one or both groins ; its longer diameter corresponding 
to the inguinal fold, its surface studded here and there with fistu- 
lous openings, and presenting at some distance soft or fluctuating 



448 LYMPHATIC VESSELS AND GANGLIA. 

points, pressure upon which forces from the mouths of the connect- 
ing sinuses a small quantity of thin, sero-purulent fluid ; the surgeon 
is at first disposed to look upon the case as one of the exceptions to 
the rule that general syphilis does not follow an open bubo, but he 
finds on inquiry that the glandular tumor is of a much later date 
than the constitutional disease ; that it followed a chancroid or ex- 
cessive sexual indulgence, or arose without any apparent exciting 
cause, and that it has clearly no direct connection with the original 
infecting chancre. Has the reader never observed a very similar 
condition in the axillae of poor, half-starved, and over-worked 
washerwomen, in whom there could be no suspicion of syphilis ? 

Whatever the depressing cause may be, it should if possible be 
removed and the system be brought into a better condition before 
benefit can be expected from local treatment. Favorable hygienic 
influences, a simple but nourishing diet, and tonics are required in 
all cases ; and, in strumous subjects, iodine, the iodides of potassium 
and iron, and cod-liver oil. Eecollect that the presence of a bubo 
by no means proves that the patient has constitutional syphilis, the 
existence of which should not be admitted until after the most 
careful and thorough examination. Should this fact be clearly 
established, specific remedies will sooner or later be required. If 
the constitutional disease be in the tertiary stage, iodide of potas- 
sium may be freely given and will prove the best tonic that can be 
found ; but mercury should be administered with great caution and 
combined with quinine or iron, or be altogether deferred until the 
general health has been improved by the means above indicated. 
No course of treatment which adds to the existing depression of 
the system will benefit the local affection. 

As the patient's health improves, the bubo generally assumes a 
more favorable aspect, and if it does not entirely heal will yield 
to remedies which were before powerless. When the sinuses are 
not too deep or extensive, they should be slit up and dressed from 
the bottom with lint, or their walls be pencilled with a crayon of 
nitrate of silver. When this course is inadmissible, I believe that 
the best results are obtained from injecting them with diluted 
tincture of iodine every few days, and applying pressure over the 
tumor by means of compressed sponge and a roller, or with Kicord's 
pad. Under one or the other of these methods they will rarely fail 
to cicatrize. In desperate cases, Eicord resorts to the destruction 
of the diseased ganglia by Vienna paste, in the following manner : 



TREATMENT OF INPUKATED BUBOES. 449 

"This caustic is applied over an extent of two-thirds of the 
tumor, so as to destroy the cutaneous surface, then on the fall of 
the eschar ; which is hastened by basilicon ointment and other 
digestives, the ganglia are attacked layer by layer ; increasing our 
caution as we proceed in depth, and stopping within accessible 
limits, or when we approach the neighborhood of vital parts. This 
method is generally very rapid, and the deep ganglia undergo 
resolution as the superficial ones are destroyed." 1 

Treatment of Indurated Buboes. — Uncomplicated cases of indurated 
buboes require absolutely no local treatment whatever. "When, 
therefore, an otherwise healthy patient with an indurated chancre 
and induration of the neighboring ganglia anxiously inquires 
whether he is likely to be laid up with a suppurating bubo, he 
may be assured that there is no danger unless he commit some 
great imprudence. Under the mercurial treatment required by 
the constitutional infection which has already taken place, the 
indurated ganglia gradually diminish in size and lose the slight 
degree of tenderness which they possessed. In the exceptional 
cases of suppuration the treatment is the same as for inflammatory 
buboes, though generally less active. 

1 Notes to Hunter, 2d ed., p. 390. 



29 



450 GENERAL SYPHILIS, 



CHAPTER IV. 

GENERAL S YPHILI S.— INTR DU CT RY REMARKS. 

The earliest manifestation of constitutional infection is the indu- 
rated chancre situated at the point where the virus entered the 
system, and the indurated bubo in its immediate neighborhood. 
These, strictly speaking, constitute primary syphilis. 1 Subsequently 
there is an interval during which the virus gives no evidence of its 
presence; but immediately following this period of latency the 
poison resumes its activity and gives rise to various symptoms, the 
seat of which has no constant relation with that of the primary sore, 
and which may occupy distant parts of the body. They are there- 
fore called "General" or " Constitutional " symptoms ; the former 
being the preferable name. The term " Consecutive," used by Vidal 
and some other authors, has been applied by Eicord to another 
class of symptoms, and to avoid confusion, should be abandoned 
as a synonyme of general syphilis. 

General Syphilis always follows a Chancre. — In the im- 
mense majority of cases of acquired syphilis (excluding those of 
hereditary origin), general symptoms can clearly be traced to a 
preceding chancre. Thus of 826 patients with constitutional 
syphilis who were treated at the Hopital du Midi in 1856, the pre- 
vious existence of a chancre in 815 was established beyond a doubt 
either by examination or by voluntary confession; in 9, there was 
strong reason to suspect it ; and in the remaining 2, the disease was 
evidently due to hereditary taint. Of 267 cases of secondary 
syphilis observed by Fournier, 2 the same fact was proved in 265. 
Of 198 cases of syphilitic erythema under the care of Bassereau, 3 
either a chancre or unquestionable traces of one were seen in 170; 
in 19, the patients confessed to the fact, although no evidence of 

1 See p. 353. 2 De la Contagion Syphilitique, Paris, 1860, p. 15. 

3 Op. cit., p. 103. 



GENERAL SYPHILIS FOLLOWS A CHANCRE. 451 

it was found upon their persons ; 4 acknowledged having had a 
gonorrhoea; 5 declared that they had had no preceding symptom. 
Thus we find that in a total of 1291 cases, general syphilis was un- 
doubtedly preceded by a chancre in all except 22. 

These statistics agree with the experience of all physicians, that, 
as an almost invariable rule, constitutional syphilis evidently origi- 
nates in a primary sore ; and the small number of cases in which 
the previous existence of a chancre cannot be established, renders 
it extremely probable that there are no exceptions to this law, 
especially when we take into account the following considera- 
tions : — 

Chancres are capable of spontaneous cicatrization, and all traces 
of them may disappear in time, even without treatment. 

They may occupy unusual situations, where their presence may 
readily escape notice, or be almost impossible to detect; among 
which the interior of the- urethra, vagina, cervix uteri, and the buc- 
cal and rectal cavities deserve special mention. 1 

Exceptional cases almost invariably rest upon the testimony of 
patients alone ; and are the more frequent, the later the constitu- 
tional lesion presented in the order of succession of syphilitic 
symptoms, in other words, the longer the time which must have 
elapsed since contagion took place. For instance, cases are rare in 
which a patient with syphilitic erythema does not confess that he 
has had a chancre ; on the contrary, they are not infrequent when 
the constitutional symptom is syphilitic rupia, tubercles, orchitis, 
or periostitis. This fact leads us to suspect that the defective 
memory of patients will explain some apparent exceptions to the 
rule. 

From various motives, patients often conceal facts within their 
knowledge. 

With perfect memory and unquestionable honesty, patients are in- 
competent witnesses upon subjects which involve medical knowledge, 
which they do not possess. The superficial chancre — the form which 
most frequently precedes constitutional syphilis — is so indolent and 
so insignificant a sore, that it may readily pass unnoticed, or, if 
seen, be mistaken for a mere abrasion. I have met with several 
instances in which patients bearing this form of chancre in plain 
sight upon their persons, were entirely ignorant of its presence, or 
thought it of no consequence. 

1 See p. 356, and also case upon p. 431. 



452 GENERAL SYPHILIS. 

A chancre may be overlooked by the patient because seated else- 
where than upon the genitals — the exclusive seat of primary sores 
in the estimation of the public — or may not be discovered, because 
concealed within the vagina, or beneath the prepuce when phymosis 
is present, or when the glans is never uncovered. In three in- 
stances, married men have applied to me with infecting chancres, 
and within four months their wives have exhibited the initiatory 
symptoms of constitutional syphilis, without having noticed or sus- 
pected the presence of a chancre which undoubtedly existed, but 
which fear of exposing the husbands prevented my searching for. 
In other cases where an examination has been made, I have found 
chancres of which patients were entirely ignorant within the vagina. 

Again, chancres are not unfrequent within the urethra beyond 
the reach of vision (see table on page 356), where an unprofessional 
person cannot be expected to be aware of their presence from the 
slight discharge, pain in micturition and induration, which con- 
stitute their only symptoms, and which may be obscured by a co- 
existing gonorrhoea. 

I repeat, therefore, that when we consider in how great a pro- 
portion of cases constitutional symptoms are known to have been 
preceded by a chancre, and when we reflect upon the numerous 
sources of error attending the testimony of patients in apparently 
exceptional cases, it is infinitely probable that a law which is 
known to be general, is in fact invariable, and that constitutional 
syphilis always follows a chancre. • 

I would add that the admission of this truth is not inconsistent 
with the communicability of secondary symptoms, but, on the con- 
trary, would favor it, provided that the latter are found by expe- 
rience to give rise to a chancre by contagion ; but of this more 
hereafter. 

Period of Incubation. — The smallpox, hooping-cough, measles, 
scarlet fever, vaccinia, and other contagious diseases, have all a 
period of incubation preceding the outbreak of general symptoms, 
and confined within certain and definite limits; so that when, 
after exposure to one of these diseases, its period of latency passes 
by and the person exposed remains in perfect health, he may be 
pronounced beyond danger. Is it probable that syphilis is an 
exception to this law ? Can it be true that, unlike all other con- 
tagious diseases, " the period of its latency is wholly uncertain and 



PERIOD OF INCUBATION. 453 

indefinite?" Only to those who refuse to watch the workings of 
nature untrammelled by art, or who rely upon the statements of 
unprofessional persons and not upon direct observation. Were it 
not for the abundant proof to the contrary to be found in many 
works upon venereal, no one would be likely to suspect the neces- 
sity of the remark, that the natural history of syphilis can only be 
learned from cases which are not influenced by treatment. Mercury 
is given for the very object of preventing or at least retarding con- 
stitutional symptoms, and if it have any effect at all, its adminis- 
tration vitiates the case for the purpose of observing the natural 
course of the disease. When left to itself, syphilis possesses as 
true, and nearly as definite a period of incubation as any other 
contagious disease ; and the contrary opinion has arisen solely from 
the causes above stated. 

In determining the duration of this period, we may take as a 
starting-point either the date of the infecting coitus or that of the 
appearance of the chancre. We shall presently see that some 
authors adopt one and some the other. The latter is perhaps pre- 
ferable, because it can generally be ascertained' by the surgeon 
with greater precision than the former. It would clearly be inad- 
missible to take as a starting-point the date of the cicatrization of 
the chancre, which is dependent upon many extraneous influences, 
and which is often subsequent to the outbreak of general mani- 
festations. 

Again, in order to obtain reliable results, it is essential that the 
termination as well as the commencement of this period should be 
ascertained with at least approximate accuracy ; and this can rarely 
be done unless the patient be under the observation of some one 
who is familiar with the early general manifestations of syphilis, 
and who knows where to look for them and how to recognize 
them ; since they are often so obscure as not to attract the attention 
of the patient himself. For instance, syphilitic erythema, which is 
one of the earliest secondary symptoms, is generally unattended by 
itching, and is often confined to the abdomen or perhaps to the 
flexures of the joints, so that the patient may be unaware of its 
presence until it is pointed out by the surgeon. The headache and 
general malaise, the post- cervical engorgement, alopecia, and acne 
capitis, which also appear at an early date, may likewise escape 
notice or not be recognized by ignorant persons. Taking these 
sources of error into account, it cannot be considered unfair to 



454 GENERAL SYPHILIS. 

reject cases -which, rest solely upon the testimonj of patients, when 
conflicting with the results of direct observation, and to adopt the 
latter as alone worthy of confidence. 

The conditions, therefore, which should be required of any case 
or series of cases brought forward to determine the natural period 
of incubation of syphilis, are : — 

1. That the date of the infecting coitus or of the appearance of 
the chancre should be known. 

2. That the patients have not been subjected to treatment. 

3. That they have been under the observation of some one 
competent to discover the earliest manifestation of general syphilis. 

If these conditions be fulfilled, the analogy drawn from other 
contagious diseases leads us to expect, that although the period of 
incubation of syphilis may vary somewhat in persons of different 
constitution, or in those exposed to different hygienic or climatic 
influences, yet that it may be defined with a great degree of accu- 
racy, and that the extremes of variation will not be far apart. Let 
us see how far these anticipations can be realized. 

The first testimony which I shall adduce is that of Diday, 1 who 
has carefully fulfilled each of the above conditions in fifty-two 
cases. In all, the patients came under observation soon after the 
development of the chancre, the exact date of which to within a few 
days was invariably ascertained, and was taken as the commence- 
ment of the period of incubation. This surgeon never administers 
mercury for primary syphilis, but, when the chancre is indurated, 
gives the patient a written statement of the time when constitu- 
tional symptoms may be expected, of the situation they will pro- 
bably occupy, the appearances they will present, and the necessity 
of his return for treatment. In none of these fifty-two cases, 
therefore, was the natural course of the disease interfered with; 
and in all, the very earliest indication of the invasion of general 
syphilis (in most instances, either headache accompanied by general 
malaise, engorgement of the sub-occipital ganglia, acne capitis, or 
an eruption upon the abdomen or arms) was observed by the sur- 
geon himself. 

The interval between the dates specified, viz., the appearance of 
the chancre and that of the earliest general symptom, was as 
follows : — 

1 Nouvelles Doctrines sur la Syphilis, p. 265. 



PERIOD OF INCUBATION". 



455 



. of Cases. In 


TERVAL IJ 


1 


25 


1 


28 


1 


33 


2 


35 


3 


36 


1 


37 


4 


38 


1 


39 


1 


40 


1 


41 


1 


42 


1 


44 


10 


45 


2 


46 



ch Days. 



No. of Cases. Interval in Days 


4 


47 


4 


48 


3 


50 


1 


52 


1 


54 


2 


56 


1 


57 


2 


58 


• 1 


60 


1 


63 


1 


70 


1 


105 



Total, 52 

It appears from this table that the shortest period of incubation 
was 25 days, and the longest 105 days, but that the latter was 35 
clays more than the one immediately preceding it. The extreme 
limits of variation are not widely separated (certainly not if com- 
pared with the variation from a few weeks to thirty years, which is 
given by some authors), and we find on examination that in by far 
the larger proportion of cases, the periods of incubation terminated 
within two weeks of each other; thus in 38 of the 52 cases, or in 
about four-fifths, this period was from 35 to 50 days. Taking the 
average of the whole number, it was 46 days. 

Yictor de Meric, Esq., Surgeon to the Eoyal Free Hospital, 
London, arrived at very nearly the same result from the observa- 
tion of nine cases in which no treatment was administered. " In 
three cases of papules, the eruption in one appeared seven weeks 
after the primary symptom ; in the other, the interval had been six 
iveeTes ; and in the last, eight weeks. Two cases of roseola or efflo- 
rescence appeared, one, twenty-four days after the occurrence of the 
chancre, and the other, one month. Psoriasis appeared in two sub- 
jects at the distance of four and eight weeks. So that we may, 
regardless of the kind of eruption, reckon a mean of six weeks where 
no treatment has been resorted to." 1 

Bassereau was able to ascertain the approximate interval between 
the infecting coitus and the outbreak of syphilitic erythema (" one of 
the earliest manifestations of general syphilis") in 107 cases in which 
no treatment was administered, and has given the results in the 
following table: — 2 



Lettsomian Lectures, 1858, p. 31. 



2 Op. cit., p. 176. 



456 GENERAL SYPHILIS. 

Erythema appeared in from 20 to 30 days in . .14 cases. 
" " " 30 to 60 " . 66 " 

" " " 60 to 90 " . . 23 " 

" " " 90 to 120 " 3 " 

" " in the course of the fifth month in . 1 case. 

Total, 107 

Bassereau adds that the appearance of erythema for the first 
time as late as the fifth month is a very rare and exceptional occur- 
rence. It should be observed that these statistics are less reliable 
than those of Diday, since many of the patients were not seen until 
some time after the appearance of the erythema, and their histories 
were obtained from their own statements. 

Fournier, 1 from an examination of 307 cases, concludes that 
syphilitic erythema most frequently appears, in the absence of 
preventive treatment, between the fortieth and fiftieth day ; and 
MacCarthy 2 states that the average is about seven weeks. 

I am myself in the habit of giving mercury for indurated chan- 
cres, and can report but four cases in which patients have been 
under my care without treatment from the commencement of the 
primary sore until secondary symptoms appeared. In the following 
instances, however, which I take from my note-book, various reasons 
induced me to defer treatment until the outbreak of general 
syphilis. 

Case 1. Chancre appeared Nov. 26, 1856, followed by general ma- 
laise, headache, pains about the joints, and papula in patches upon the 
forehead, Jan. 29, 185T. Period of latency, 64 days. 

Case 2. Chancre appeared April 2, 1857 ; syphilitic roseola May 12. 
Interval, 40 days. 

Case 3. Chancre first seen Jan. 1, 1859 ; mucous patches upon scro- 
tum and internal surface of cheek, acne capitis, and post-cervical engorge- 
ment, Feb. 15. Interval, 45 days. 

Case 4. Chancre developed Feb. 2, 1859; syphilitic roseola appeared 
March 13. Interval, 40 days. 

I have also met with frequent instances in which patients who 
had received no treatment, applied to me with early symptoms of 
general syphilis without being able to give the exact time of the 

1 Notes to Ricord's Lecons sur le Chancre, 2d ed., p. 466. 

2 These de Paris, 1844. 



PERIOD OF INCUBATION. 457 

appearance of the chancre, but it has invariably been stated that 
this occurred within the preceding three months. 

Ricord, as the result of his extensive experience, enunciates the 
law that "when no. specific treatment is administered for an infect- 
ing chancre, and the disease is left to itself, six months never pass 
without the appearance of general symptoms ;" and he adds, " in 
most cases, these supervene from the fourth to the sixth week ; 
frequently during the second or third month ; and very rarely as 
late as the fifth or sixth month." " M. Puche has verified the same 
fact in hundreds of cases, without meeting with a single excep- 
tion." 1 

Prof. Sigmund, of Yienna, in order to determine the duration of 
the incubation of general syphilis, examined the notes of 1473 cases 
occurring in his own practice, and from these selected 293 as es- 
pecially reliable, because copulation had occurred but once or only 
after a long interval, and because the primary sore had received no 
specific treatment. In none of these 293 cases did general symp- 
toms fail to appear within three months. The chancre took on 
induration (reckoned by Sigmund among general symptoms) in 
261 ; the lymphatic glands were affected in all, the fauces in 248 ; 
spots appeared on the skin in 204 ; and papulse, pustules, and con- 
dylomata, either alone or combined, were present in 134. Sigmund, 
however, calls attention to the fact that the early symptoms of gen- 
eral syphilis may occasionally be so slightly marked or so obscure, 
that they will not be discovered or will not be recognized by in- 
competent persons ; and it is only in such cases, he asserts, that the 
tardy appearance of late secondary and tertiary manifestations has 
given any semblance of truth to the assertion that the incubation of 
syphilis can be indefinitely prolonged. Sigmund lays down the 
rule, that when a chancre heals without induration, and when, no 
specific treatment being administered, secondary symptoms do not 
appear within the first three months, the patient has nothing farther 
to fear. 2 

Cazenave is the only author of any eminence whose statistical 
observations would appear to controvert the position which I have 
here advocated. This distinguished physician of the Saint Louis 
Hospital, founding his opinion upon only seven cases, estimates 

1 Ricord, Lettres sur la Syphilis, 2d ed., p. 300. 

2 British and For. Med.-Chir. Rev., Jan. 1857, from the Wien Wochenschrift, 
No. 18. 



458 GENERAL SYPHILIS. 

the average interval between contagion and the development of 
syphilitic erythema at nearly two years. In one instance, he states 
that it was ten years, but the syphilitic nature of the disease may 
well be doubted, since the patient was cured by a few simple vapor 
baths and barley water ; and if this case be eliminated, the average 
duration will be much diminished. Moreover Cazenave's position 
at a hospital for skin diseases, where patients are not seen until a 
long time after contagion, and where consequently the sources of 
error already referred to cannot well be avoided, detracts from the 
value of his observations, which cannot compare in number and 
importance with those of the observers before quoted. Bassereau, 1 
who served as Interne both at the Hopital des Yeneriens and at 
the Hopital Saint-Louis, states that syphilitic erythema was very 
common at the former, but that he met with only one case during 
his year's residence at the latter; and adds that this affection is 
not even mentioned in the work upon syphilitic eruptions by MM. 
Martins and Legendre, who collected their cases at the Saint-Louis, 
where they were internes with him. Thus we have direct proof 
that the above objection to Cazenave's testimony is not without 
foundation. 

Vidal 2 avoids expressing an opinion upon this subject, but refers 
with apparent approval to Cazenave's statement; and also adds, 
" M. Legendre, un des eleves les plus distingues de l'Hopital Saint- 
Louis, auteur d'une these remarquable sur les syphilides, dit en 
propres termes: 'J'ai obtenupour moyenne generale de l'intervalle 
de temps qui separe les symptomes primitifs des syphilides (acci- 
dents secondaires) cinq ans, resultat absolument semblable a celui 
que M. Martins avait deja consigne dans son memoire.' " Unfortu- 
nately for the value of this testimony, which alone is quoted in 
full by Yidal, M. Legendre has since written a letter to Diday, 3 in 
which he states that the words in brackets (" accidents secondaires ") 
are an interpolation; that his meaning has thus been misrepresented 
and made to support an untenable doctrine ("pour batir un point de 
doctrine insoutenable ") ; that his statistics include tertiary as well 
as secondary syphilitic eruptions; and that he "never intended to 
assert that my (his) patients had, on an average, passed five years 
without having syphilitic roseola, which is frequently overlooked, 

' Op. cit., p. 48. 
, 2 Traite des Maladies Veneriermes, p. 261. 
5 Nouvelles Doctrines sur la Syph., p. 270. 



PERIOD OF INCUBATION. 459 

but which is none the less an evidence of the existence of the first 
stage of general infection of the system." I should not have re- 
ferred to this error, had it not very naturally been reproduced in 
the American edition of Vidal on Venereal, and been copied into 
a recent work on "Gonorrhoea and Syphilis ;" in both of which the 
liability of misleading the reader has been increased by interchang- 
ing the words "syphilides" and "accidents secondaires," and placing 
the former instead of the latter in brackets. 

I have dwelt thus at length upon this question, not only on ac- 
count of its scientific interest, but because it is one of great prac- 
tical importance both to the patient and surgeon, and because I 
have desired to leave no doubt as to its correct solution. If it be 
true that the incubation of syphilis is "wholly uncertain and indef- 
inite," the unfortunate individual who contracts a chancre, the 
nature of which is doubtful, can never feel secure for the rest of his 
days, nor be sure that his posterity will not inherit this great curse ; 
but if, as I believe, it is of certain and definite duration, the lapse 
of a few months without the appearance of the disease will place 
the patient beyond danger. To the surgeon the conclusions at which 
we have arrived furnish the strongest inducement in all chancres 
of a doubtful character to defer general treatment, and keep the 
patient under careful observation until secondary symptoms appear, 
or until the period of latency is passed in safety. 

To sum up this whole matter : — 

A chancre which is not subjected to specific treatment (so-called), 
will generally, if at all, be followed by secondary symptoms ivithin 
three, and always within six months. 

It follows as a corollary from this proposition and the one upon 
page 450, that 

The earliest symptoms of general syphilis (except. in cases of hered- 
itary origin and of transmission through the foetal circulation) have 
been preceded by a chancre, probably ivithin three, and certainly ivithin 
six months. 

I will merely add that the development of general syphilis is 
hastened by an elevated temperature, and by those causes which 
tend to depress the vital powers, as excessive or prolonged exer- 
tion, or a dissipated course of life ; and that it is, on the other hand, 
retarded by the contrary influences, and also by the supervention 
of an acute disease, as continued fever, inflammation of the lungs, 
etc. It also appears to be earlier in women, in whom mucous 



460 GENERAL SYPHILIS. 

patches are developed with great rapidity, sometimes even three 
weeks after contagion. 

Classification of General Symptoms. — Eicord's classification 
of constitutional .symptoms into secondary and tertiary, which is 
generally adopted at the present day, is founded upon Hunter's 
division of the tissues affected by syphilis into "parts first in order, 
and parts second in order." Both systems are based upon the con- 
formity by nature to laws which are more or less fixed as well in 
disease as in health, and upon the anatomical structure of the parts 
affected. An important distinction, also, which Eicord claims to 
exist between the two divisions in this classification, is a difference 
in the effect of remedies ; secondary symptoms being more suscep- 
tible to mercury, and tertiary to iodine and its compounds. 

Eicord's classification may best be given in his own words: 
" Secondary symptoms are the consequence of the absorption of 
the virus, and are transmissible by hereditary descent, without 
being inoculable. Tertiary symptoms are not only not inoculable, 
but cannot be transmitted by hereditary descent under their pecu- 
liar type, although in consequence of a kind of degeneration or 
modification of the syphilitic virus, they are probably one of the 
most fruitful sources of scrofula. 

" Secondary symptoms rarely occur before the third week follow- 
ing the appearance of primary symptoms, and more rarely still after 
the sixth month; whilst tertiary symptoms scarcely ever appear 
before the sixth month, and may not until after several years. 

" To secondary symptoms are referred certain affections of the 
skin (syphilitic eruptions), and of some parts of the mucous mem- 
branes (mucous patches, condylomata and superficial ulcerations) 
and their dependencies (alopecia and onyxis) ; also some peculiar 
pathological affections of the eyes (iritis), lymphatic ganglia (en- 
gorgement of the glands in various parts of the body, especially 
the neck), etc. Tertiary symptoms consist of certain changes 
which take place in the subcutaneous or submucous cellular tissue 
(gummy tumors), in the testicles (orchitis), in the fibrous and 
osseous tissues (periostitis, ostitis, caries, etc.), and in the deeper 
organs. 

"Proper treatment of primary symptoms may prevent the de- 
velopment of secondary symptoms. Yery often this treatment 
cures the primary and arrests only the secondary symptoms; in 



CLASSIFICATION OF GENERAL SYMPTOMS. 461 

this way may be explained, for example, the late appearance of 
diseases of the periosteum and bones, without the secondary link, 
in persons who have taken mercury. When once the primary 
ulcer is healed, it cannot be reproduced except by a new contagion ; 
while secondary and tertiary symptoms may appear repeatedly, and 
at various intervals, within periods which cannot be limited. An 
apparent inversion in the succession of secondary and tertiary 
symptoms is observed only in persons who have undergone treat- 
ment. After the appearance of constitutional symptoms, the 
syphilitic diathesis may cease spontaneously or in consequence of 
appropriate treatment, and yet the symptoms persist under the 
influence of purely local causes, as is observed especially in many 
cases of diseased bones." 1 

In another place Eicord says of tertiary symptoms : " They not 
only differ from primary and secondary symptoms in affecting the 
deeper tissues, but also in the fact that in them syphilis loses, in 
part, its peculiar type. Though the skin is often affected at this 
period with the most severe tubercular eruptions, yet the subcu- 
taneous and submucous cellular tissues, and the fibrous and osseous 
systems are far more frequently involved. But, in addition to these 
parts, where the tardy effects of constitutional syphilis are so common 
and clearly admitted by all good observers, we may well inquire 
whether there be any privileged tissues of the body which are 
invariably exempt from its effects. We would inquire, also, if 
syphilitic infection, though it may not produce all the evils with 
which it is reproached, be not in a multitude of cases the cause of 
the evolution, or 'putting into action' — to use an expression of 
Hunter's — of diseases which have previously existed in a latent 
state, and of which it is thus only the exciting cause. Observation 
replies in the affirmative to these questions, and also teaches us that 
tertiary symptoms may continue under the influence of the virulent 
cause, or persist as local effects after this cause has been destroyed 
or neutralized by treatment ; it shows, in a multitude of cases, that 
the syphilitic virus, after having been the cause of other diseases, 
may cease to exist or persist as a complication ; and these are cir- 
cumstances which, though real, are unfortunately not always easily 
appreciated. 

" Tertiary symptoms rarely occur before the sixth month follow- 

1 Notes to Hunter, p. 396. 



462 GENERAL SYPHILIS. 

ing the appearance of the primary ulcer, and the latter seldom re- 
mains at the time of their development ; but they are frequently 
attended by some secondary symptom. They never furnish in- 
oculable secretions, nor transmit characteristic constitutional syphilis 
from parent to child ; their only hereditary influence being the fre- 
quent transmission of a taint as injurious and almost as fearful, viz., 
a scrofulous diathesis." 

Eicord's classification may, I think, be resolved into two parts. 
The first is the chronological system, which, originating with Fer- 
nel and Hunter, has been freed from many errors by Eicord, and 
greatly perfected by this surgeon's keen powers of observation, and 
which is both natural and eminently practical. The second part 
consists of various additions relative to the inoculability of the dif- 
ferent orders of symptoms, their transmission by hereditary descent, 
and the effect of treatment ; some of which are open to criticism. I 
shall speak of each in turn. 

The general symptoms of syphilis are not drawn at hap -hazard, 
but make their appearance with a great degree of order and regu- 
larity. This fact is most apparent in those lesions which follow 
immediately upon the period of incubation, and which vary but 
little in different subjects. Allow any patient with an infecting 
chancre to go without treatment, and it may be predicted with 
almost absolute certainty, that within three months he or she will 
be attacked by the following category of symptoms with but little 
variation, viz., general lassitude, accompanied by headache and 
fleeting pains in various parts of the body ; an eruption of blotches 
or papulae upon the skin; pustules upon the hairy scalp ; engorge- 
ment of the post-cervical glands ; and whitish patches, which may 
become ulcerated, upon the mucous membrane of the mouth, anus, 
or vulva. 

Subsequent to the first outbreak of general syphilis, the same 
uniformity does not prevail ; and certain symptoms are absent in 
one case and present in another, or they appear to be modified by 
the constitution of the patient, the hygienic conditions in which he 
is placed, his habits, and especially by treatment. But if we take 
a number of cases, some of which supply what is wanting in 
others, we find that we can, as it were, make up a complete series, 
in which the symptoms progress by a regular gradation, and may 
be divided into two classes, distinguishable by the time of their 
appearance, their character, and their seat. Those of the first class 



CLASSIFICATION OF GENERAL SYMPTOMS. 463 

follow immediately upon the earliest constitutional symptoms before 
mentioned, with which they are evidently identical in character. 
Those of the second class never occur until after a certain interval 
which experience enables us to determine with great precision. 
Again, the order of the two classes is never reversed. For instance, 
a patient who has been suffering with symptoms belonging to the 
second, as deep tubercles of the cellular tissue or caries of the bones, 
is never known to exhibit the premonitory fever, exanthematous 
eruption, and other early symptoms of the first. The disease pro- 
gresses with greater rapidity in some cases than in others, yet owing 
to the general uniformity referred to, simple inspection of a patient 
will enable any one familiar with its natural course to arrive at an 
approximate conclusion as to the length of time that has elapsed 
since contagion, and also as to the character of the preceding symp- 
toms, unless these have been altogether suppressed by treatment. 

Apparent exceptions to the regular succession of the general 
symptoms of syphilis are met with, and may readily deceive an 
inexperienced observer. One of the most frequent of these is due 
to treatment. It often happens that a patient had an infecting 
chancre many years ago, and perhaps early secondary symptoms, 
for one or both of which he took mercurials ; a long period has since 
passed without further general manifestations ; but his system has 
continued under the syphilitic diathesis, which finally becomes active 
again and gives rise to tertiary lesions. Evidently the exemption 
from late secondary symptoms may be ascribed to mercury. 

Again, the date of the first appearance of any lesion determines 
its position in the syphilitic scale; while its persistency may be due 
to many causes, too numerous to mention. It is a very common 
occurrence for a chancre to remain until secondary symptoms break 
out ; but we do not therefore conclude that both belong to the same 
order. In the same way, secondary are often present long after 
tertiary manifestations have supervened. In Eicord's admirable 
remarks already quoted, allusion has been made to the fact which 
I have often had occasion to verify, that syphilis may give rise to 
symptoms, which are continued by various causes and especially 
by a strumous diathesis, long after the exciting cause has been 
subdued. Moreover, many syphilitic lesions, and particularly 
eruptions upon the skin and mucous membranes, may, either with 
or without treatment, disappear, and again return within a limited 
period with the same characters as at first. This tendency, how- 



464 GENERAL SYPHILIS. 

ever, ceases with time ; and relapses after a considerable interval 
are in all cases rare. For instance, syphilitic erythema which 
usually appears about the sixth week after the development of the 
chancre, may perhaps return as late as the eighth or ninth month, 
but never several years after the primary sore. 

Finally, the same name is, in several instances, applied to symp- 
toms which are in reality distinct, and which are widely separated 
upon the syphilitic scale. Thus there is a form of alopecia which 
is one of the earliest general symptoms, and in which the hair is 
freely shed from the scalp and eyebrows, but may grow again, since 
the hair-bulbs are not seriously affected ; and there is another and 
rarer form, observed only in the later stages of syphilis, in which 
the whole integumental surface becomes permanently bald. Two 
forms of iritis, ecthyma, etc., are also observed at distinct periods ; 
but these constitute no exception to the law of succession of syphi- 
litic symptoms. 

We thus see that a simple chronological division of constitutional 
symptoms may be maintained ; but there are several objections to 
the additions made to this system by Eicord, as I shall proceed to 
show. 

In the first place, Eicord's statement that " secondary symptoms 
are not capable of inoculation," is true in the guarded sense in 
which it was intended, viz., that they are not inoculable upon the 
persons bearing them ; but the inference which was also designed to 
be conveyed, that they differ in this respect from infecting chancres, 
is not true, as Eicord himself has since acknowledged. Both are 
contagious and inoculable upon persons free from syphilitic taint, 
but neither are auto-inoculable. 

Again, Eicord's statements relative to tertiary symptoms cannot 
at the present day be implicitly received. This author maintains 
that tertiary lesions are not inoculable and cannot be transmitted 
by hereditary descent under their peculiar type, and hence that 
the virus in this stage must be entirely changed from its original 
character. The first of the above assertions is doubtful, the second 
incorrect. The inoculability of tertiary symptoms has never been 
tested upon persons free from syphilitic taint, and its possibility, there- 
fore, may yet be demonstrated, as that of secondary symptoms has 
been. Their transmission by hereditary descent in many instances, 
still preserving their peculiar type, is a known fact. The most fre- 
quent instance of this is the occurrence of syphilitic hepatitis and deep 



CLASSIFICATION OF GENERAL SYMPTOMS. 465 

tubercles of the subcutaneous cellular tissue in infants affected 
with, hereditary syphilis. Dr. Wm. H. Tan Buren ; Professor of 
Anatomy at the University Medical College, jS". Y., has also ob- 
served nodes upon the forehead and ulna, and syphilitic orchitis 
in several instances, and has kindly furnished me with notes of 
the following case occurring at his clinique : — 

James Harmon, aged 14 months, was brought to the clinique, Oct. 22, 
1853. The patient is the fifth child, his mother having had in addition 
two miscarriages. 

The first child died five weeks after birth, and had, when born, an erup- 
tion on the face, arms, and legs, and around the corners of the mouth. 
The second child, born three years after, had an eruption in much the 
same localities, appearing about three weeks after birth, and died in nine 
months. The third child, born three years after the second, had a similar 
eruption, but lived nearly two years. The mother then had two miscar- 
riages in succession. The fourth child also had an eruption appearing 
about three weeks after birth, and lived sixteen months. 

This child is now fourteen months old. About three weeks after birth, 
he also had an eruption making its appearance on the face and arms, and, 
in the course of three months, on the legs and around the anus, which 
was cured by "a blue powder" (hyd. cum creta?). 

About three months ago (July, 1853), both of the testicles of this child 
commenced slowly and painlessly enlarging, and have gradually increased 
in size up to the present time. Both are extremely hard and irregular to 
the feel. The child also presents a small node upon the forehead and 
periosteal thickening over the ulna, and appears to be suffering from great 
muscular debility, and its appetite is poor. 

It is unnecessary to enter into the details of the treatment of this case. 
Suffice it to say that the nodes entirely disappeared under the administra- 
tion of the iodide of potassium. Both testicles suppurated; one after- 
wards healed and returned to its normal size; the other was in an indolent 
condition and still discharging at last record. 

Two similar cases have recently occurred at the Hospice des 
Enfants-Sainte-Anne, at Vienna j 1 and Tirchow 2 has found small 
collections of the deposit peculiar to tertiary syphilis in the cerebral 
substance of children born of syphilitic mothers. 

1 Syphilis Tertiaire chez des Enfants, L ! Union Medicale, Atrg. 11, 1860, from the 
Wien Medizin YTochenschr. 

2 La Syphilis Constitutionnelle, traduit de rAllemand par le Dr. Picard, Paris, 
1860, p. 4. 

30 



466 GENERAL SYPHILIS. 

Hunter attributed the difference in the situation of early and late 
constitutional symptoms to the influence of cold, which, as he sup- 
posed, rendered the more superficial parts of the body most sus- 
ceptible to, and earliest affected by the virus. This anatomical 
distinction, without Hunter's explanation, has been retained in 
Eicord's classification, in which the skin and mucous membranes 
on the one hand, and the osseous, fibrous, and cellular tissues on the 
other, are regarded as the exclusive seat of secondary and tertiary 
manifestations respectively. But this rule cannot always be main- 
tained, since one of the earliest symptoms of general syphilis — 
preceding in many cases the eruption upon the skin — consists of 
pains resembling rheumatism, some of which are evidently seated 
in the periosteum (chiefly that of the cranium and in the neighbor- 
hood of the joints), and this fibrous tissue has been known to take 
on acute inflammatory action at this time. In order to avoid this 
difficulty, Bassereau asserts that general syphilis attacks indiffer- 
ently the integumental, fibrous, and osseous structures in all periods 
of the disease, but that the more superficial portions of each are 
affected in the earlier and the deeper in the later stages. 

Virchow 1 would exclude all consideration of situation from the 
classification of general symptoms, and has proposed a system 
based upon the nature of the pathological changes in the different 
lesions, but which is too widely at variance with the ideas at pres- 
ent received to meet with general adoption. Be Baerensprung 2 
offers a similar classification in which secondary symptoms are 
made to include those lesions which are characterized by hypersemia 
and simple exudation ; and tertiary symptoms those in which there 
is tubercular deposit. 

But it is easier to pull down than it is to build up, and attempts 
in the latter direction may well be deferred until many preliminary 
points are settled. Meanwhile, we have every reason to be satisfied 
with the simple and natural chronological division which forms the- 
basis of Eicord's classification, and which owes its excellence in a 
great measure to the keen powers of observation of this truly 
eminent surgeon. The few errors which he introduced are not 
essential to the system, and may well be forgotten, when we recol- 
lect his important contributions to our knowledge of the natural 
history of syphilis. 

1 Op. cit. 2 Annales de la Charite, vi. p. 56, et vii. p. 173. 



symptoms of syphilis contagious. 467 

Some of the Symptoms of Gexekal Syphilis aee Contagious. 
— The older writers on syphilis fully believed in the contagiousness 
not only of secondary symptoms, but also of the sweat, saliva, semen, 
milk, blood, and even the breath of persons- affected with constitu- 
tional syphilis. Hunter, founding his opinion upon a few unsuc- 
cessful inoculations of secondary symptoms upon the persons 
bearing them, declared that the power of contagion was confined to 
primary sores. Auto-inoculations, similar to those of Hunter, were 
repeated in thousands of instances by Eicord, and, in imitation of 
his example, by numerous surgeons in various parts of the world, 
the results of which were uniformly unsuccessful with scarcely an 
exception worthy of notice. On the other hand, the chancroid was 
regarded by Eicord and by the profession generally as the type of 
primary sores, and its secretion was found to be inoculable with 
the greatest facility. The inference which was drawn was a natural 
one, viz., that a radical distinction existed between primary and 
secondary lesions in the contagiousness of the former and the in- 
communicable character of the latter ; and the zeal, energy, and 
ability with which this idea was for many years defended are 
known to the whole medical world. 

The plausibility of this evidence, the immense number and uni- 
form results of the experiments resorted to, the keen powers of 
observation, ingenious reasoning, attractive manners, and evident 
sincerity of the Surgeon of the Hopital du Midi, united in adding 
weight to a doctrine which had already been sanctioned by the 
great name of Hunter, and which was consequently for a time 
received as almost beyond dispute. Yet cases in apparent contra- 
diction to Eicord's "law" were met with by many careful observers, 
especially in infants affected with hereditary syphilis, whose early 
age, incapacitating them from sexual intercourse, greatly dimin- 
ished the chances of error of observation ; and although instances 
of transmission of secondary symptoms from the nursling to the 
nurse, and vice versa, were explained away with great ingenuity 
by Eicord and his adherents, yet they gradually came to be 
admitted by the majority of the profession. At the same time 
it was felt to be highly desirable to demonstrate this power of con- 
tagion by experimental inoculation, and thus place it beyond a 
doubt ; and afterwards to study the phenomena of the process and 
compare them with those attending the evolution of constitutional 



468 GENERAL SYPHILIS. 

syphilis when originating in a chancre. Until this was done, the 
subject was likely to remain an open question. 

This test, however, could not readily be applied. Eicord and 
his school — to their honor be it said — had confined their inocula- 
tions to persons already infected, and it was generally admitted that 
further experiments, in order to be decisive, must be made upon 
those who were free from syphilitic taint — a course which could 
not be justified in a moral point of view even for the purpose of 
advancing science. Wallace had already, in 1835, succeeded in 
inoculating the secretion of condylomata upon healthy individuals, 
but the want of precision in his observations rendered them of 
little value. Subsequent inoculations, however, within the last ten 
years, by Waller of Prague, Einecker of Wurzburg, a surgeon of 
the Palatinate who has concealed his name, Gribert and Yidal of 
Paris, and others, can leave no further doubt that the contagious- 
ness of secondary symptoms can be demonstrated by the lancet. 1 

Gibert's experiments, although by no means the most conclusive 
that have been published, have probably attracted the most atten- 
tion in this country, since they ostensibly formed the basis of a 
report in favor of the contagiousness of secondary syphilis, which 
was adopted by the Academy of Medicine of Paris, at its session 
of May 31, 1859, and during the discussion of which Eicord gave 
in his qualified adhesion to the same doctrine. These cases are 
as follows : — 

Case 1. Patient No. 1, Saint-Charles ward; an adult affected with 
lupus of the face, which he had had since infancy. A vesicated surface 
was produced upon the left arm by aqua ammonise, and charpie soaked in 
the purulent secretion of secondary mucous patches situated around the 
anus was applied to the raw surface. 

The patient from whom the matter was taken presented around the anus 
a corona of condylomata (pustules plates) which had already existed for 
a fortnight, and which were consecutive to a chancre of the prepuce con- 
tracted fifteen months before, the cicatrix of which was still apparent. 

Jan. 30, 1859, five days after the inoculation, no trace of the latter was 
visible except the mark of the blister, which was about the size of a ten- 

1 A resume of the inoculations of Wallace and Waller may be found in the 
Arch. Gen. de Med. for Feb. 1856 ; and of those of Rinecker.and the anonymous 
surgeon of the Palatinate in the same journal for May, 1858. Vidal's experiments 
are given in his Treatise on Venereal. 



SYMPTOMS OF SYPHILIS CONTAGIOUS. 469 

cent piece. Nine days later all vestige of the blister had disappeared, 
but a little redness was seen at the same spot. 

Feb. 12, the eighteenth day after the inoculation, a prominent copper- 
colored papule appeared. 

Feb. 16 (the twenty-second day), a small quantity of serous exudation 
appeared on the surface of the papule, which in the meanwhile had spread 
and increased in size generally. This secretion becomes purulent, and 
forms by concretion a thin scab. 

Feb. 23 (the twenty-ninth clay), an enlarged gland is found in the cor- 
responding axilla, 

Feb. 26 (the thirty-second day), the scab is detached by a vapor bath, 
when a very superficial excoriation is found beneath it. 

March 21 (fifty-fifth day), a superficial ulceration, slightly excavated, 
has formed in the centre of the papule, which has become more and 
more prominent and indurated, and now constitutes a true tubercle. 
Moreover, several blotches and reddish papules have appeared upon the 
body ; subsequently they are transformed into pustules resembling acne, 
and this eruption becomes general upon the anterior surface of the upper 
extremities, upon the abdomen, internal surface of the thighs, inguinal 
regions, etc. 

March 31, the patient is directed to take a mixture of the biniodide of 
mercury and iodide of potassium in syrup, and baths containing corrosive 
sublimate. 

May 16, after six weeks' treatment the ulcerated tubercle upon the 
arm has disappeared, leaving behind it a white and slightly depressed 
cicatrix. The enlarged ganglia in the axilla remain. The general syphi- 
litic eruption is beginning to disappear. 

Case 2. Patient No. 47, Saint-Charles ward. A vigorous adult, affect- 
ed with an inveterate papulo-tubercular lupus, which covers the whole 
face. 

Several inoculations were made in the same manner and with the same 
matter as in the preceding case. Two of these succeeded and gave rise 
to the same local changes, but preceded by a longer period of incubation, 
which was a little less than twenty-five days. Slight redness then showed 
itself, followed by the development of a papule, which was at first dry, 
then became moist, excoriated, covered with a scab, indurated, and finally 
formed a true condyloma {tubercule plat). A ganglion in the axilla at the 
same time enlarged to the size of a hazel-nut. An eruption of roseola 
appeared upon the body on the fifth of March; that is to say, on the 
thirty-seventh day following the inoculation. Specific treatment was 
commenced a short time after; and on May IT following, the cure 
appeared to be complete. 



470 GENERAL SYPHILIS. 

Case 3. This case presents a striking analogy with the two preceding, 
except that the papule was much smaller, and the tubercular induration 
was less marked, less extended, and underwent resolution more rapidly, 
leaving a rounded, superficial, and slightly fungous ulceration. Specific 
treatment was commenced before the appearance of the roseola. To-day 
(May 11) the patient is rapidly improving. The inoculation was per- 
formed Feb. 28, 1859. The matter employed was the viscous and plastic 
secretion from the papular surface of patient No. 1, whose local sore was 
at that time sixteen or seventeen days old. 

Case 4. This case is more interesting in respect to the source from 
which the virus was taken (a scaly papule upon the forehead)-, the appear- 
ance of the matter itself (there was only bloody serum upon the lancet 
when withdrawn) ; the long duration of the incubation (about thirty-five 
days) ; and finally the form of the initial lesion, which, during its whole 
duration, presented no other appearance than that of a scaly papular sur- 
face, without secretion or excoriation. 

The patient who furnished the matter for the inoculation had been treated 
by M. Puche, at the Hopital du Midi, for an indurated chancre upon the 
external surface of the prepuce. At the time of his entrance into our 
wards (Feb. 1, 1859), this chancre had left in its place an indurated cica- 
trix, still a little red, in the form of a condyloma, and lenticular and indo- 
lent engorgement of the inguinal ganglia. Secondary mucous patches 
had been developed upon the penis, scrotum, the internal portions of the 
thighs, and anus, and had thence extended to other portions of the body. 
Upon the forehead was a large scaly patch, of a coppery red color, entirely 
dry, and about the size of a ten-cent piece. 

Feb. 9, the point of a lancet was plunged into the circumference of this 
patch, and charged with slightly serous blood, which was at once inocu- 
lated upon the palmar surface of the right forearm of a patient affected, 
like the preceding, with lupus of the face. As we had no idea that this 
inoculation would succeed, we allowed the patient, a fortnight after, to 
leave the hospital. All traces of the puncture had at that time entirely 
disappeared. 

April 1st following, this young man re-entered the hospital under the 
care of M. Bazin. At this time (fifty days after the inoculation), we were 
surprised to find that there had been developed at the point of inoculation 
a reddish papule, which was spread out in an irregular form, entirely dry, 
and about the size of a ten-cent piece, and which thus resembled the 
scaly patch upon the forehead from which the virus was taken. 

The patient reported that this patch appeared about fifteen days before, 
which was thirty-five days after the inoculation. Above and around it 
were seen several slightly prominent and coppery spots, the commencement 



SYMPTOMS OF SYPHILIS CONTAGIOUS. 471 

of a squamous syphilitic eruption, which subsequently extended to other 
parts of the body. A painful ganglion, larger than a hazel-nut, was found 
in the corresponding axilla. 

April 23, the patient's condition was as follows: blotches of roseola 
upon the body; a few scattered scaly papules upon the anterior surface 
of the upper extremities; an abundant eruption upon the scalp; engorge- 
ment of the posterior cervical ganglia; commencing mucous patches about 
the umbilicus and the margin of the anus; no symptoms about the mouth, 
throat, or genital organs. 

Specific treatment was soon commenced, and by May 18th all the symp- 
toms were much improved. 

Gibert attempts to justify these inoculations on the ground that 
the patients were all affected with inveterate lupus of the face, 
which he hoped to benefit " by the double influence of a new con- 
stitutional disease and the specific remedies administered in its treat- 
ment ;" and he has since stated that in three of the four cases this 
hope was realized and the patients entirely cured of their lupus; 1 
this statement, however, requires confirmation, and the author has 
not escaped severe and just censure for inoculating syphilis upon 
persons who must have been ignorant of the risk they were incur- 
ring. 

Looking at Gibert's cases from a purely scientific point of view, 
they are deficient in detail and in accuracy of observation, and could 
not be received in proof of the contagiousness of secondary syphilis, 
were the latter not sustained by clinical experience and the more 
reliable experiments of others. A sceptic in this doctrine would 
naturally say : " These cases prove nothing. — No exploration was 
made of the rectum of the patient from whom the matter was de- 
rived for the first two inoculations. This cavitj- may have con- 
cealed a chancre, the secretion of which was mingled with that of 
the mucous patch upon the margin of the anus. — Nor is it said 
that the patient bore any other evidences of constitutional infection. 
How do we know that the sore which he had upon the penis fifteen 
months before was not a chancroid, and that his supposed con- 
dyloma was not a recent infecting chancre, undergoing a process of 
transformation into a mucous patch or tubercle, as often takes place 
during the reparative stage ? — Owing to one or the other of these 
sources of error, which were not guarded against, the secretion of a 

1 Gaz. des Hopitaux, No. 144, 1859, from the G-az. Medicale. 



472 GENERAL SYPHILIS. 

primary instead of a secondary lesion was inoculated. No wonder 
a chancre was the result, the secretion of which was employed in 
the third successful inoculation. — The fourth case is vitiated by the 
absence of the patient from observation during thirty-five days 
between the inoculation and the outbreak of constitutional symp- 
toms ; during which time he may have been exposed to many other 
sources of contagion." 

These objections are not without foundation, and it is certainly 
not unfair to conclude that the Academy of Medicine did not rest 
its adoption of the report of its committee upon the experimental 
inoculations which it contained, but rather upon the large amount 
of evidence drawn from clinical experience which has for years 
been accumulating, and probably also upon the more reliable ex- 
periments of others, although the latter were not properly under 
discussion at the time. The conclusions of the report of the com- 
mittee were as follows : — 

1. Some secondary or constitutional symptoms of syphilis are 
manifestly contagious. The mucous patch or tubercle holds the 
first rank in this respect. 

2. This truth is applicable both to the nurse and nursling and 
also to persons in general ; and there is no reason to suppose that 
the secretion of secondary symptoms in infants at the breast pos- 
sesses different properties from those which are known to belong 
to secondary symptoms in adults. 1 

The objections which I have brought against Gibert's inocula- 
tions, as recorded in his report, are well founded, and would 
justify a medical jury in pronouncing the verdict, " not proven ;" 
but at the same time, considering the standing of their author and 
the concordance of the results with those of other observers, I have 
no doubt, in my own mind, that the matter employed was derived 
from the sources supposed; If this be so, the first two cases were 
instances of the successful inoculation of secondary symptoms. In 
the third (admitting with Eollet that secondary symptoms give rise 

1 The exact words of the original are as follows : — 

1. II j a des accidents secondaires ou constitutionnels de la syphilis manifeste- 
ment contagieux. En tete de ces accidents, il faut placer la papule muqueuse ou 
tubercule plat. 

2. Ce fait s'applique a la nourrice et au nourrisson comme aux autres sujets, et 
il n'y a aucune raison de supposer que chez les enfants a la mamelle le produit de 
ces accidents ait des proprietes differentes de celles qu'on lui connait chez l'adulte. 



SYMPTOMS OF SYPHILIS CONTAGIOUS. 473 

to a chancre by contagion), the matter inoculated was that of a 
primary sore. In the fourth (if the lesion upon the forehead be 
correctly described by Gibert), the blood of a syphilitic patient 
was successfully inoculated. 

The interest attached to the decision of the Academy of Medicine, 
and to the occasion of Kicord's renunciation of a doctrine which he 
had so long and ably defended, is my reason for making Gibert's 
inoculations so prominent; but, as before stated, no one can for a 
moment suppose either from the character of the experiments or 
from reading the discussion before the Academy, that the event was 
anything more than the enunciation of a foregone conclusion. The 
contagiousness of secondary symptoms had already been proved by 
clinical experience, and its demonstration accomplished by the more 
carefully conducted experiments already referred to. Of the latter 
I shall only quote those reported by Rinecker, as entirely conclu- 
sive and sufficient in themselves to establish the point in question 
without the assistance of any others. 

Case 1. A woman by the name of Bronner, aged 28, was admitted to 
the hospital in the fourth month of pregnancy, to be treated for constitu- 
tional syphilis. Her symptoms were syphilitic acne, mucous patches and 
severe leucorrhcea, without any traces of primary symptoms. After a 
mercurial treatment she was dismissed, July 7, as cured. Nov. It, she 
gave birth to a daughter, whom she was not able to nurse. 

Her child appeared to be healthy at birth, but, on Dec. 9th, was at- 
tacked with sore mouth and diarrhoea, which yielded to the administration 
of nitrate of silver. On the 13th, large condylomata were found upon 
the genital organs and on the internal surface of the thigh. Soon after 
a specific eruption appeared upon the face, and this was soon accompanied 
by the most clearly marked symptoms of hereditary syphilis : such as an 
affection of the nails, syphilitic nodus, etc. The child grew thin and pale, 
and died Jan. 12, 1852. 

A servant girl who took care of the infant during its illness, but who 
did not nurse it, became affected; mucous tubercles were developed at the 
right angle of the mouth, and followed their usual course ; the genital 
organs were examined with the greatest care, and found to be intact. 

Prior to the death of the infant, a young physician, W. R., offered, 
for the interests of science, to allow himself to be inoculated with the 
secretion from the pustules of acne upon the child. He was 24 years old, 
of a robust and healthy aspect, had never had syphilis, and consequently 
was a very favorable subject for this experiment. Wallace's method was 
adopted with slight modifications ; and Jan. 5, 1852, a blister three inches 



474 GENEKAL SYPHILIS. 

long by two inches wide was applied to his left arm ; the serum was 
evacuated ; and the matter from several pustules upon the child's fore- 
head was introduced beneath the epidermis, which was not removed from 
the vesicated surface. 

Jan. 10, there was no appreciable effect ; the blister had followed its 
usual course, and, with the exception of slight redness and exfoliation, was 
completely healed. 

Jan. 20, a short time after the healing of the blister, a papular erup- 
tion attended with severe pruritus, such as often follows the application 
of a blister, appeared over the whole arm, but disappeared without treat- 
ment. 

Feb. 2. The result of the inoculation appeared very doubtful, when, on 
Jan. 25, the surface which had been blistered became red again, desqua- 
mated, and itched. At this date (Feb. 2), twenty-nine days after the 
inoculation, the surface is of a deep red and copper color, corresponding 
exactly to the limits of the blister. The skin is hard and infiltrated es- 
pecially toward the circumference, and at the inferior and internal angle, 
where the matter employed in the inoculation was deposited in a larger 
quantity than elsewhere. In these portions, are seen a number of 
papular elevations, from the size of a lentil to that of a pea, and firm. 
No pain. 

Feb. 10. All the inoculated surface is covered with tubercles of a 
brownish-red color, hard to the touch, united in groups, and covered for 
the most part with scales. Those which first appeared bear upon their 
summits a dark scab, produced by an exudation of pus. 

Feb. 15 (forty-two days after the inoculation), the isolated tubercles, 
especially those at the internal and inferior angle, have decidedly increased 
in size. They are now quite prominent, and are covered by a conical scab 
which reminds one of rupia, and beneath which suppuration has taken 
place. The skin is very much infiltrated, especially around the margins. 
There is a little pain following the lymphatic vessels. The axillary gan- 
glia are swollen and tumefied. 

We now attempt to make the eruption, which is thus far local, recede 
by means of frictions with an ointment containing the biniodide of mer- 
cury. This treatment at first appears to succeed ; the tubercles diminish 
in size ; the infiltration begins to disappear, and in a fortnight the largest 
tubercles are the only ones remaining visible. The ointment is suspended 
for. some time, when the local affection grows worse, and, March 14, 
seventy days after the inoculation, the skin again becomes red and more 
infiltrated. Still we do not despair of preventing general infection, and 
apply a paste consisting of equal parts of chloride of zinc and starch to 
the local sore. After the fall of the eschar, healthy granulations appear, 
and cicatrization progresses rapidly. 



SYMPTOMS OF SYPHILIS CONTAGIOUS. 475 

June 12 (one hundred and fifty clays after the inoculation, and one 

hundred and thirty after the appearance of the local affection), 1 R , 

who until this time had been quite well, complained of malaise, gastric 
disturbance and headache. A week later, an erysipelatous redness ap- 
peared upon the anterior wall of the soft palate, and a few days after a 
grayish-white exudation upon the same part, which was soon transformed 
into a superficial ulceration. A similar spot appeared upon the internal 
surface of the lower lip, and another upon the side of the frsenum linguae, 
and the occipital ganglia were slightly affected. Mucous patches appeared 
at a later date upon the scrotum. 

Mercury internally and an appropriate regimen effected a cure in the 
course of a few weeks, and at the present time (Nov. 20), there have been 
no new symptoms of constitutional syphilis. 

I shall not quote in full Einecker's second case, which is a mere 
continuation of the first, since the matter employed was taken from 

the tubercles upon the arm of E ; and, if we adopt the recent 

views of the nature of the sore produced by the contagion of con- 
stitutional syphilis, it was, as in Gilbert's third case, the secretion 
of a primary and not a secondary lesion which was inoculated. 
Suffice it to say, that matter from this source was applied in the 
same manner as in the former case, to the arm of another physician, 
Dr. "Warnery, of Lausanne, Feb. 13th. 

The phenomena which ensued were very similar to those in the 
preceding case. The blistered surface entirely healed, but, March 
13th (twenty -three days after the inoculation), became red again, 
was infiltrated and thickened, and presented numerous firm, papular 
elevations, which, by March 21st, were transformed into prominent 
tubercles, covered with brownish scabs or thin grayish scales. An 
ointment of biniodide of mercury was used as in the former case, 
but about May 1st (from one hundred and sixteen to one hundred 
and twenty clays after the inoculation, and from fifty -four to sixty 
days after the appearance of the local sore), Dr. W. was attacked 
with numerous and unquestionable symptoms of constitutional 
syphilis, of which Einecker gives a minute description. 2 

In discussing this question I have not considered it necessary to 
adduce proof from clinical experience in favor of the contagiousness 
of secondary lesions occurring in infants affected with hereditary 

1 This long incubation of general syphilis was probably due to the mercurial 
frictions. 

2 These two cases were originally reported to the Physico-Medical Society of 
Wurzburg, and are inserted in the third volume of their Transactions. 



476 GENERAL SYPHILIS. 

syphilis, because examples of this kind abound in medical litera- 
ture. The reader will find numerous instances recorded in Diday's 
work on Infantile Syphilis, a translation of which has recently been 
published by the New Sydenham Society. But let it not be for- 
gotten that this is the most favorable field for the study of this 
question, since syphilitic infants almost invariably present second- 
ary lesions upon the buccal mucous membrane, and the contact 
between the infant's mouth and the nurse's breast, is more frequent, 
prolonged, and intimate, than often occurs between any two surfaces 
in adults equally liable to be affected by constitutional lesions. 

Moreover, cases of transmission of secondary symptoms between 
grown persons are almost always open to the suspicion that the 
disease was contracted in some other way. A number of cases, 
however, of undoubted character, have been reported by Eollet, 1 
and others, thus disproving Diday's idea, that hereditary syphilis 
possesses a peculiar virulence, and is alone capable of being com- 
municated by contagion. In the first of Eollet's cases, the disease 
was transmitted from the mouth to the breast, in the same manner 
as commonly occurs in infants. 

Case 1. Mme. X was delivered of a healthy female infant, Oct. 

30, 1856. As the child did not readily take the breast, a woman was 
engaged to come to the house every day, and draw off the milk. By the 
month of Jan., 185*7, a fissure had formed upon the nipple, attended with 
engorgement of the axillary ganglia, but had finally healed. 

The patient was under the care of Dr. Despiney, who afterwards dis- 
covered unmistakable signs of constitutional syphilis, but, fully persuaded 
of her virtue and that of her husband, suspected that he was mistaken in 
his diagnosis, and, the following May, referred her to Rollet, who found 
that she had syphilitic erythema, alopecia, scabs upon the head, engorge- 
ment of the suboccipital ganglia, mucous patches upon the mouth, grayish 
spots upon the tonsils, but no lesion of the genital organs. These symp- 
toms had existed for a fortnight. Her husband was perfectly well, and 
had never had any venereal trouble. 

Rollet, with considerable difficulty, ascertained the above mentioned 
particulars with regard to her milk having been drawn off, and, on 
examining her breasts, found at the base of the left nipple a large 
characteristic induration, and two glands of the size of a nut, not pain- 
ful, in the axilla. 

It was learned on inquiry that the woman who had sucked the breasts, 

1 Archives Gen. de Med., March, 1859. 



SYMPTOMS OF SYPHILIS CONTAGIOUS. 477 

was virtuous, but bad had syphilitic lesions upon the genital organs, 
which were communicated by her husband, and which had healed without 
treatment. She had afterwards had mucous patches upon the fauces, and 
at the same time with her attendance upon Mme. X . 

The infant was now examined and found affected with an ulceratiou 
of the lip, which disappeared under a mercurial course that was at once 
commenced. It, however, afterwards had mucous patches around the 
anus and the genital organs. 

The mother was cured for a time of her symptoms, but had several re- 
lapses. The husband never presented any syphilitic lesion. 

Case 2. Jules C , silk-weaver, aged 25, entered the Antiquaille 

Hospital, Lyons, June 26, 1858. He had never had any venereal disease 
until April 11 preceding, when he was bitten upon the upper lip by Louis 
B., and the wounds produced by the aggressor's teeth remained open for 
two months. 

At his entrance into the hospital, two masses of induration were found 
in the upper lip ; each of which nearly equalled in size a twenty-five cent 
piece, and was slightly excoriated upon the surface. The submaxillary 
glands on each side were enlarged and indolent. 

He had had for several days scabs upon the head, alopecia, erythema 
upon the body, and mucous patches upon the scrotum ; nothing upon the 
penis. He was ordered to take pills of the protiodide of mercury, and 
baths containing corrosive sublimate, and left the hospital July 8, before 
he was quite well. 

His wife presented no trace of syphilis, and was nursing at the time a 
healthy infant. 

Louis B , who bit him, and who was condemned for the act to six 

months' imprisonment, had been treated for general syphilitic symptoms 
at the hospital which he entered April 10, 1857, when, as shown by the 
records, he had an indurated chancre of the corona glandis, which healed 
at the end of three weeks. He afterwards had mucous patches upon the 
scrotum, engorgement of the posterior cervical ganglia, and alopecia; for 
which he remained under treatment until May 8, when he left the hos- 
pital. 

At the time when he seized Jules C. between his teeth, he had syphi- 
litic lesions in the mouth, and told the latter as he bit him that he would 
give him the pox. 

Case 3. Antoine S , aged 20, contracted an indurated chancre 

upon the penis in April, 1858, which, after existing for some time, healed 
without treatment. He afterwards had a papular syphilitic eruption, 
sore throat, and excoriated patches upon the mucous membrane of the 
lips. 



478 GENERAL SYPHILIS. 

He was^exaniined by Rollet, Dec. 15, 1858, when he presented the fol- 
lowing symptoms : A large, cartilaginous, and pathognomonic induration, 
half of which was upon the glans penis, and half upon the prepuce towards 
the left side; well-marked multiple adenitis in the left groin ; a mucous 
patch at the left commissure of the lips ; traces of an eruption upon the 
legs and thighs. 

S. was a worker in a glass-foundry, where it is the custom among the 
men who blow the bottles to work by threes; the first blows the glass 
into a hollow globe, and passes the tube to the second, who modifies the 
form in some way, and he to the third, who finishes the bottle. S. was 
the first of a set who blew in the same tube. 

John J , aged 21, the second of the same set, perceived, in Octo- 
ber, 1858, a hard lump, the size of a cherry-stone, on the anterior and 
right side of the lower lip, and a short time afterwards the sub-maxillary 
ganglia, especially on the right side, became engorged. At a later date, 
which the patient could not state with accuracy, an ulceration with a 
grayish floor appeared on the right tonsil and on the anterior wall of the 
palate. 

The patient was examined Dec. 10, 1858, when a reddish and indu- 
rated patch was found at the spot already mentioned upon the lip; there 
was multiple sub-maxillary adenitis ; an ulceration upon the right tonsil ; 
nothing whatever upon the genital organs. 

Fleury Gr , aged 42, was the third of this set of glassblowers. He 

was examined Dec. 10, 1858, and presented several ulcerations, which he 
said had existed about a month. One was situated upon the mucous 
membrane of the lower lip near the median line ; its floor was reddish and 
raw, and partly covered with a blackish scab ; its edges irregularly cut ; 
its diameter nearly half an inch. 

A second ulceration was seated upon the internal surface of the upper 
lip ; its floor grayish and pultaceous; its edges sharply cut; its depth less 
than the preceding. 

A third ulcer also occupied the upper lip ; it was grayish, of small ex- 
tent, and would perhaps admit the head of a pin. 

On examining the mouth, a mucous patch was found between the uvula 
and the left posterior pillar of the palate ; the fauces were generally red, 
and the patient experienced difficulty in swallowing. The submaxillary 
ganglia were sensibly engorged, and also to a less degree those upon the 
side of the neck. G. has no lesions of the genital organs. He is married 
and the father of a family. His children are all well, but he states that 
he has communicated the disease to his wife, who, however, could not be 
examined. 



SYMPTOMS OF SYPHILIS CONTAGIOUS. 479 

Case 4. M. X , aged 25, of a good constitution, consulted Rollet 

in April, 1849, for an indurated chancre of the prepuce, which completely 
healed after three weeks' treatment 

In the month of Aug., the patient presented symptoms of constitutional 
syphilis ; scabs upon the head, alopecia, engorgement of the sub-occipital 
ganglia, erythema of the fauces with superficial ulceration of the tonsils, 
mucous patches upon the sides of the tongue, a papular eruption upon the 
body and extremities, and mucous patches around the anus. Antisyphi- 
litic treatment was again administered, under which all the symptoms dis- 
appeared, with the exception of the mucous patches in the mouth, for 
which the patient refused to continue treatment. 

In September, 1850, Rollet was called to a family in which M, X. was 
quite intimate, and found a girl aged 18, who presented upon the lower 
lip a prominent patch, of a circular form, grayish at the centre, and ap- 
parently covered with a false membrane ; a similar but smaller patch was 
visible upon the corresponding part of the upper lip, and the sub-maxillary 
glands were engorged. The diagnosis was not at this time made out, 
although an ointment containing calomel was prescribed. 

Six weeks afterwards, the affection of the lips was nearly in the same 
condition, but other symptoms had supervened which left no doubt as to 
the nature of the disease. These were : mucous patches upon the sides of 
the tongue; erythematous inflammation of the fauces; a pustular eruption 
upon the scalp; lesions upon the vulva which her mother said resembled 
the mucous patches in the mouth. An antisyphilitic treatment was now 
commenced. 

As soon as Rollet recognized the syphilitic nature of the disease in the 
girl, he suspected M. X., whom he knew to be still affected with mucous 
patches of the mouth; and upon telling him his suspicions, he confessed 
that he had been in the habit of kissing her and had given her the disease 
in this manner. M. X. also stated that he had had sexual relations 
with another woman, whom he requested Rollet to visit lest he might 
have also infected her. Rollet did so, and found that she had an ulcer- 
ated patch upon the lower lip. She had recently become pregnant, and 
subsequently miscarried and exhibited unequivocal symptoms of consti- 
tutional syphilis. . 

Case 5. One of the most esteemed druggists at Lyons, requested Rollet 
to visit Mrs. X., a woman of irreproachable character, but in whom the 
druggist thought that he recognized symptoms of syphilis. 

The patient was 22 years old; of a lymphatic temperament; had been 
married three years, but had had no children. She was first seen by 
Rollet in April, 185*7, in the presence of her mother. 

Three months before, this woman first perceived upon her lower lip an 



480 GENERAL SYPHILIS. 

ulcer, which she supposed was a mere crack or fissure. It had gradually 
been enlarging, and the sub-maxillary ganglia had become indurated. 
About a month before, scabs had appeared upon the head, together with 
alopecia, sore throat, and a general eruption upon the body. 

When seen by Rollet, there was well-marked elastic induration of the 
lower lip ; the sub-maxillary ganglia were swollen and slightly painful ; 
the whole body was covered with a papulo-vesicular eruption. Erythe- 
matous inflammation of the fauces, pain in deglutition, engorgement of 
the sub-occipital ganglia, coryza and alopecia were also present. The 
genital organs were sound. 

There could be no doubt of the nature of the disease; but, before ex- 
pressing an opinion, Rollet requested the mother to retire, and then told 
his patient that she had syphilis, and asked her if she wished it to be kept 
secret. She did not hesitate a moment, but desired her mother called in 
again, in whose presence the subject of the origin of the infection was dis- 
cussed. Neither the wife nor mother accused the husband, who was a 
man of very regular habits ; and both expressed the wish that he should 
be present at the second examination. 

The husband was 35 years old, of a good constitution, and confessed 
that he had had syphilis at the age of 22, which had been perfectly cured 
at the Strasbourg Hospital. He had had no subsequent symptoms, and, 
upon examination, was found to be perfectly sound. 

Finding that the husband did not accuse the wife, nor the wife the 
husband, that there was no attempt whatever at concealment, and taking 
into consideration that the first symptom had been a chancre upon the 
lip, Rollet, after a long examination and inquiry, became convinced that 
his patient had derived her disease from her cook, who was found to 
have a copious eruption of mucous patches upon the fauces, a pustular 
eruption upon the scalp, alopecia, and other unequivocal syphilitic symp- 
toms ; and both she and her mistress were in the habit of tasting out of 
the same spoon the dishes prepared for the table. 

Rollet relates a number of other, and no less remarkable instances 
of the transmission of secondary syphilis between adults, all of 
which, considering the high standing of their author, are entitled 
to confidence. Founder 1 also gives the details of four cases, in 
which indurated chancres were undoubtedly produced by contagion 
from mucous patches or secondary ulcerations in adults affected 
with acquired syphilis. 

Dr. Samuel S. Purple, of New York, has also related to me 
several instances in which there could be no reasonable doubt that 

1 De la Contagion Sypliilitique, Paris, 1SG0, p. 77. 



SYMPTOMS OF SYPHILIS CONTAGIOUS. 481 

syphilis was communicated by young men affected with, mucous 
patches of the mouth to young women to whom they were engaged. 

But in spite of the immense amount of evidence in proof of the 
contagiousness of constitutional lesions (but a small portion of 
which has here been given), it may well be doubted whether this 
question could be regarded as satisfactorily and definitely settled, 
were it not for the recent investigations relative to the chancrous 
virus and the properties of the infecting chancre, which have 
removed all obstacles to the admission of this doctrine, and have 
thus furnished another beautiful instance in the history of science 
of the light thrown upon one subject by the study of another. So 
long as the two species of chancre were confounded, and the chan- 
croid was regarded as the chancre-type, it was impossible not to 
believe that a radical distinction existed between primary and 
secondary lesions, and that the former were inoculable and the latter 
not inoculable upon persons bearing them ; and it was highly pro- 
bable, also, that as the properties of the one were known to be the 
same in respect to healthy individuals, those of the other were so 
also. But since the discovery that the infecting chancre alone 
pertains to true syphilis, and that it is not auto-inoculable, the 
same mode of reasoning, independently of direct proof, leads to the 
conclusion that the properties of primary and secondary syphilitic 
lesions, in respect to contagion, are exactly the reverse in infected 
and healthy persons. 

The contagion of syphilis in its primary as well as secondary 
forms is now known to coincide with that of other infectious dis- 
eases, all of which are innocuous to persons already under their 
influence, but virulent to those who have never been affected by 
them; and while, in considering this subject, we cannot but be 
struck with the beautiful harmony of nature in disease, we may 
well feel humble at the thought that so plain a lesson from analogy 
should for so long a time have been disregarded. 

It is a remarkable fact, as noticed by Eollet, that artificial inocu- 
lation has frequently demonstrated the contagiousness of secondary, 
but seldom that of primary lesions. The number of successful 
inoculations of the former upon healthy individuals now amount 
to twelve or more, while those of the latter do not exceed three, 
and in two of these (the third of Gibert's inoculations and the 
second of Einecker's already quoted), the authors supposed they 
31 



482 GENEKAL SYPHILIS. 

were inoculating secondary lesions; the third was performed by 
Eollet. 

Eepeated inoculations of the secretion of secondary symptoms 
upon persons afflicted with cancer have invariably failed, whence 
it has been supposed that an antagonism exists between the cancer- 
ous diathesis and syphilis. 

What Constitutional Symptoms are Contagious? — By far the larger 
number of successful inoculations of general symptoms have been 
performed with matter taken from mucous patches, condylomata, 
or superficial ulcerations of mucous membranes, all of which lesions 
may be regarded as essentially the same or nearly identical ; and, 
so far as I have been able to ascertain, all cases of contagion from 
constitutional symptoms which have been observed in practice have 
been produced by matter from the same class of sores. 

In Einecker's first case, the matter was derived from syphilitic 
acne, and Vidal has inoculated with success the contents of the 
pustules of ecthyma. Blood was used in one of Waller's cases. 
The same fluid was employed in nine inoculations by the anony- 
mous surgeon of the Palatinate, three of which were successful ; 
and it is almost certain, I think, that this was also the active agent 
in Gibert's fourth case. 

The great frequency of mucous patches upon those parts of the 
body (the vulva in women, and the mouth in both sexes, especially 
in infants), which are most exposed to contact with other persons, 
explains why such lesions should be the most common source of 
contagion among constitutional manifestations. The artificial inocu- 
lations of Tidal and Einecker prove that pustular syphilitic erup- 
tions are also contagious; and it is highly probable that the same 
property is possessed by all constitutional symptoms which are 
attended by a serous or purulent secretion, but it is difficult to 
believe that any of the dry forms of the disease, without the pre- 
sence of fluid capable of absorption, are communicable. 

The contagiousness of the blood of syphilitic persons — if merely, 
as is probable, in a slight degree only — is a fact of great importance, 
which is sustained by a large amount of evidence drawn from the 
communicability of other contagious diseases by means of the 
circulating fluid, 1 and demonstrated by the five cases of successful 

1 A resume of this evidence may be found in an admirable paper by Dr. 
Viennois on the Transmission of Syphilis by Vaccination, published in the Arch. 
Gen. de Med. for June, 1860. 



WHAT CONSTITUTIONAL SYMPTOMS CONTAGIOUS. 483 

I 

inoculation already referred to. It is, indeed, true that repeated 
attempts by other surgeons to inoculate this fluid have failed ; for 
instance, eighteen inoculations performed by Diday (16 in June, 
1848, and 2 in September, 1849) were all unsuccessful ; but in a 
matter of this kind a few well conducted cases of success are of 
greater weight than many failures. 

Waller's inoculation was performed upon a boy aged 15, who 
had never had syphilis. From three to four drachms of blood 
were taken from a patient affected with secondary syphilis, and 
applied to the cuts produced by the application of a scarificator. 
At the end of three days, the wounds had entirely healed, but, 
thirty-four days after the inoculation, two distinct tubercles 
appeared, which finally coalesced and ulcerated. Sixty-five days 
after the inoculation, and thirty-two days after the appearance of 
the tubercles, a well-marked syphilitic roseola was developed upon 
the abdomen, back, chest, and thighs. The whole body became 
covered with the eruption, and some of the blotches upon the 
thighs were transformed into papulse. The diagnosis was con- 
firmed by a number of competent physicians who saw the case. 

In the experimental inoculations of the blood by the surgeon of 
the Palatinate, it is stated that those only succeeded in which the 
fluid was applied to an extensive absorbing surface, which was 
made raw by friction. 1 

Dr. Yiennois has adduced satisfactory evidence to show that 
many instances of the transmission of syphilis by vaccination are 
due to the lancet having been charged with blood taken from 
syphilitic persons. No opportunity will be more convenient than 
the present to state the following results at which this author has 
arrived from his thorough and exhaustive researches relative to 
the connection between vaccination and the transmission of syphi- 
lis ; and I regret that my space will not permit a fuller notice of 
his investigations, for which I must refer the reader to the original 
paper in the Archives Generates de Medecine for June, 1860. 

1. Vaccination with pure vaccine matter is sometimes the ex- 
citing cause of the appearance of a syphilitic eruption in infants 
already under the syphilitic diathesis ; -in the same manner that it 
gives rise to non-specific eruptions in strumous subjects. The 
history of the case and the order of evolution of the symptoms 

1 Revue Critique, par le Dr. Lasegue, Arch. Cren. de Med., May, 1858, p. 604. 



484 GENEKAL SYPHILIS. 

are generally sufficient to establish the diagnosis. For instance, 
the appearance of the eruption within a few days or weeks after 
the vaccination, without the ordinary period of incubation of syphi- 
lis, will render it probable that the disease was already latent in 
the system. 

2. Syphilis cannot be transmitted to a healthy person by the 
inoculation of vaccine matter taken from a syphilitic subject, unless 
the lancet at the same time be charged with blood ; in which case 
an infecting chancre is produced followed by general symptoms in 
their usual order of evolution. 

Two of the most remarkable instances of the transmission of 
syphilis by vaccination are those reported by M. Lecoq 1 : — 

Case 1. May 4, 1858. P., aged 25 years, was re vaccinated in accord- 
ance with the regulations of the marine service to which he belonged ; 
three punctures were made upon each arm. The vaccine virus was de- 
rived from healthy-looking pustules upon the arm of another soldier, who, 
it was afterwards learned, had had an indurated chancre upon the penis 
three months before. Eight days after P.'s vaccination, it was found that 
the pustules had aborted ; one of them, however, became inflamed a 
short time after and took on ulceration, which gradually assumed the 
characters of an indurated chancre; its base was hard to the touch, and 
a number of indurated ganglia were felt in the corresponding axilla. 
Subsequently a syphilitic eruption appeared, and other constitutional 
manifestations. 

Case 2. D., aged 25, was also revaccinated on the same day and 
with matter from the same source. The result was similar to that de- 
scribed in the preceding case, viz., failure of the vaccination ; ulceration 
of one of the punctures, which spread, became indurated, and was attended 
by multiple engorgement of the axillary ganglia ; at a later period, con- 
firmed constitutional syphilis. 

In a letter to M. Yiennois, M. Lecoq gives the following additional 
details relative to these cases: "The matter was taken from perfect 
vaccine pustules, which had been normally developed, upon the arm of a 
soldier who, though we were ignorant of it at the time, had had an indu- 
rated chancre upon the penis three months before, for which he was 
treated for two months at the hospital. He had not the slightest trace 
of syphilitic symptoms at the time the matter was taken from his arm. 

44 The lancet employed in the operation was new; had never been used 

• Guyenot, These de Paris, 1859. See also Gazette Hebdomadaire, 27 Janv. 1860. 



WHAT CONSTITUTIONAL SYMPTOMS CONTAGIOUS. 485 

for the purpose before, and cannot be supposed to have been in any way 
at fault. 

" Several soldiers were vaccinated on the same day, with the same 
matter, and by the same person ; and in only two did any unpleasant 
results occur. 

"The two soldiers, in whom syphilitic symptoms supervened, had never 
had any venereal disease, and were remarkably healthy. Every induce- 
ment was offered to make them confess that they had been exposed by 
impure coitus, but without effect; they persisted in their denial, and no 
cicatrix could be found upon the genital organs." (In another letter M. 
Lecoq states that these two men were the last of those who were vacci- 
nated that day; and that he recollects that the pustule being nearly ex- 
hausted of lymph, a little blood was drawn by the lancet.) 

" The development of the vaccine pustules in these two men was care- 
fully watched, and, after the fourth day, was found to be quite irregular. 
The pustule was not umbilicated as usual, and was soon covered with a 
thick scab, beneath which there was an ulceration, which was at first 
small, but which rapidly increased in size and in depth; so that in a few 
days it involved the whole thickness of the derma, and equalled in size a 
two-franc piece. Its edges were irregular and abrupt ; its surface very 
painful ; it bled readily, and during the night became covered with a scab, 
beneath which sanious pus was imprisoned ; its edges were very decidedly 
indurated and the axillary ganglia engorged. These ulcers did not heal 
for two months, and required to be cauterized several times. The cica- 
trices were swollen, a little painful, and indurated, and prone to ulcerate 
if rudely handled; they did not become firm until after anti-syphilitic treat- 
ment. Three punctures were made upon each arm, but only one in each 
patient followed the above course. 

"About six months after vaccination, eruptions appeared, which, to our 
great surprise, were decidedly syphilitic. 

" One of the men had a persistent roseola, pustules of acne upon the 
back and arms, pustules of impetigo upon the scalp, engorgement of the 
cervical ganglia ; and, at a later period, copper-colored patches of pso- 
riasis upon the back and arms. 

"The other had impetiginous scabs upon the head, engorgement of the 
cervical ganglia, and mucous patches upon the scrotum and internal por- 
tions of the thighs, and, later, around the anus. 

"The symptoms in both patients disappeared under the administration 
of the bichloride of mercury and iodide of potassium." 

Numerous instances of a similar character, in some of which the 
disease spread to a large number of persons, have been collected by 
M. Viennois, and are sufficient to show that although vaccination 



486 GENERAL SYPHILIS. 

is commonly a harmless operation, yet that it may, if proper pre- 
cautions be omitted, be the means of transmitting a fearful consti- 
tutional disease. 

Admitting the contagiousness of the blood of syphilitic persons, 
we might from d priori reasoning suppose that the various fluids 
which are secreted from the blood, as the saliva, milk, sweat, and 
semen, are also contagious, and this was the belief of the earlier 
writers on syphilis. At the present day, however, we find but few 
advocates of the contagiousness of any of the secretions mentioned 
except the milk and semen, and the latter alone will at present 
occupy our attention. 

It is an established fact that the seminal fluid of a syphilitic 
father may infect an ovum in the womb of a healthy mother, who 
may herself be contaminated through the foetal circulation ; but the 
question at issue is whether a woman, without becoming pregnant, 
may contract syphilis by cohabitation with a man affected with the 
syphilitic diathesis, but who at the time presents no syphilitic lesion ; 
in other words, whether the semen possesses the same contagious 
properties that are known to exist in the secretions of primary and 
secondary lesions, and in the blood. Now the supposition that this is 
possible is not at all unreasonable, but it is an axiom in the study 
of the natural sciences that nothing should be admitted as true 
which is not susceptible of demonstration, or which is not supported 
by the strongest analogy, and if we receive as a fact that which is 
merely not improbable we at once open the door to error ; more- 
over, now that the contagiousness of syphilis is known not to be con- 
fined to primary sores, we must carefully guard against the reactive 
tendency which will probably follow to extend its limits beyond 
the bounds of truth. 

It should be required of all cases adduced for the purpose of 
proving the contagiousness of the semen, that the fact should be 
well established that the man had no syphilitic lesion at the time 
of intercourse ; that the woman was not otherwise exposed, and did 
not become pregnant; and that the evolution of her syphilitic 
symptoms coincided with that which invariably follows contagion 
from other sources; hence that a primary sore appeared at the 
point where the virus entered the system, and that general symp- 
toms ensued in their usual order, and after their usual period of 
incubation, as after the transmission of the disease by the secretion 
of a primary or secondary symptom, or by the blood ; and I do not 



WHAT CONSTITUTIONAL SYMPTOMS CONTAGIOUS. 487 

hesitate to say that these conditions have never been fulfilled in a 
single instance. 

One of the ablest advocates of the contagiousness of the sperm is 
Dr. W. H. Porter, of Dublin, the author of a series of Essays on 
the Natural History of Syphilis?- which have deservedly attracted 
much attention. While entertaining the highest respect for the 
opinion of this writer, I feel obliged to dissent from his views upon 
this subject. The cases which he reports appear to me to be unre- 
liable, because based upon the statements of patients alone, and not 
upon accurate observation ; in some of them, it is by no means cer- 
tain that the disease was not communicated through impregnation 
or otherwise, and it is assumed in all that no primary sore existed, 
a fact not material to the question, in the opinion of Dr. Porter, 
who says : " Often, in discussions on this subject, I have been met 
by an inquiry whether the woman spoken of had been examined 
by the speculum, and if it was not quite possible that chancres 
might have existed deep in the recesses of the vagina or the uterus. 
2" never did make such examination, nor will one ever be made under 
similar circumstances, because there is no symptom to attract atten- 
tion in that direction ; but if a chancre did so exist ; it must either 
have been the product of illicit intercourse, or communicated by a 
husband, who had no ulcer on himself, and, consequently, no pus 
in which the poison could be conveyed. It is of no consequence 
whether there was a chancre or not, for its existence or non-existence 
forms no part of the case sought to be established, which has refer- 
ence to the poisoning powers of the seminal fluid." I have taken 
the liberty of putting in italics those portions of this quotation to 
which I would especially call the reader's attention, and which I 
think support the conclusion above expressed with regard to the 
slight value of Dr. Porter's cases. While admitting that he never 
examined the genital organs of a woman under these circumstances, 
I am at a loss to understand how Dr. Porter can lay down the pro- 
position, as an established law of syphilis, "that the semen of a 
diseased man deposited in the vagina of a healthy woman will, by 
being absorbed, and without the intervention of pregnancy, contami- 
nate that woman with the secondary form of the disease, and that 
without the presence of a chancre, or any open sore, either on the 
man or the woman ;" and to establish this proposition, so contrary 

1 Dublin Quart. Jouru. of Med. Sci., May, 1857. 



488 GENERAL SYPHILIS. 

to all that is known of the contagion of syphilis, would require a 
large amount of unquestionable evidence, in which there should be 
no possibility of the disease originating through impregnation, or 
" illicit intercourse." It is highly improbable that the transmission 
of syphilis, by means of the semen in the absence of pregnancy, 
if possible at all, should follow laws differing widely from those 
which govern contagion arising from other sources. 

Syphilis pursues essentially the same course, whether 
derived from a primary or secondary symptom; in the lat- 
ter case, as in the former, the initial lesion is a chancre. — 
At a discussion before the Societe Medicale du Pantheon, of Paris, 
in 1856, relative to the contagiousness of secondary symptoms, Dr. 
Edward Langlebert stated his suspicions, founded upon two cases 
of secondary contagion which had come under his observation, that 
the initial lesion was a chancre. 1 This idea, at first advanced with- 
out any adequate proof, excited but little attention, until, in 1858, it 
was taken up anew by a distinguished surgeon of Lyons, M. Rollet, 
who subjected it to the test of comparison with a large number of 
cases of secondary contagion which were to be found in medical 
literature, adduced additional facts from his own experience in its 
favor, and, in short, was able to sustain it by such an amount of 
evidence, that there could remain but little doubt of its truth. 
Judging from my own impressions, upon first reading Bollet's con- 
clusions, which were published in the Archives Generates de Mede- 
cine, for February, March, and April, 1859, they will appear to one 
who has never heard of them before as novel and ingenious, but 
not entirely satisfactory; but they certainly grow in favor the more 
they are thought of; and, above all, the more closely they are com- 
pared with those cases of secondary contagion which have been 
published without any preconceived notions as to the phenomena 
which would ensue, the more reasonable and reliable do they ap- 
pear. I would recommend the reader to peruse again the cases of 
transmission of syphilis from secondary lesions and the blood, which 
have been quoted in the present chapter, at the same time bearing 
in mind the evolution of the disease when following contagion 
from a primary sore, and he cannot fail to observe the great simi- 

1 Proceedings of the above society for 1856, p. 8. See also a letter from M. 
Langlebert to M. Diday, Gaz. Med. de Lyon, July 1, 1859. 



SECONDARY CONTAGION PRODUCES A CHANCRE. 489 

laritj between them; in fact, so slight is the difference as to con- 
stitute no serious objection to the doctrine of MM. Langlebert and 
Eollet. 

It may be remarked at the outset that this doctrine is supported 
by analogy. All other contagious diseases follow the same course, 
whether the disease from which they were contracted was, at the 
time of contagion, in its commencement or near its termination. If 
one person communicate variola, scarlet fever, or measles to an- 
other, the symptoms in the latter do not exhibit any variation in 
consequence of the early or late stage of the affection existing in 
the former at the period of communication, A slight difference in 
the time occupied by the vaccine pustule in reaching maturity in 
vaccinations with the fresh lymph and those with the dry scab has 
been noticed, but no variation in the symptoms has ever been 
detected. Hence we may reasonably suppose that syphilis will also 
pursue the same course, whether derived from a primary or second- 
ary lesion ; but, after all, this is a question which must be decided 
by an appeal to facts. 

In submitting this doctrine to the test of experience, I propose 
to compare in general the phenomena following contagion from 
each of these two sources, but to pay particular attention to the 
initial lesions, with regard to which there is most likely to be a 
diversity of opinion. It will be well, therefore, in the first place 
to inquire what constitutes a chancre. 

I have elsewhere denned a chancre " the initiatory lesion of ac- 
quired syphilis, arising at the point where the virus enters the sys- 
tem, and separated from the general manifestations of constitutional 
infection by a period of incubation." The essentials of a chancre, 
then, as I understand them, are, a sore developed at the point of 
contagion as the earliest symptom of acquired syphilis, the appear- 
ance of which is followed by a period of latency as regards the 
virus, and subsequently by general syphilis. We shall presently 
see that if this definition be received as correct, there can be no 
hesitation in admitting that the initial lesion of syphilis from second- 
ary contagion is a chancre. 

But there are minor conditions which enter into our ideas of a 
true infecting chancre (as at present understood), and which are as 
follows : a period of incubation between contagion and the appear- 
ance of the primary sore; ulceration varying in extent and depth, 
and which may involve only the epidermis or epithelium; and, in 



490 GENERAL SYPHILIS. 

the great majority of cases, induration of the base of the sore and 
of the neighboring lymphatic ganglia. It is only with respect to 
a few of these points that any doubt is admissible as to the identity 
of the chancre following primary and that produced by secondary 
contagion. 

With these preliminary remarks I proceed to a comparison of 
the phenomena in the two cases. 

1. The earliest symptom following secondary {as in cases of primary) 
contagion is a sore developed at the point where the virus enters the sys- 
tem. — Artificial inoculations, to which we can alone refer for the 
establishment of this fact, prove it to be true without exception. 

2. This sore is preceded by a period of incubation, like the ordinary 
infecting chancre. — In all cases of artificial inoculation of secondary 
symptoms and of the blood, the inoculated point has remained qui- 
escent for a number of days before the appearance of the initial 
lesion. In twelve cases collected by Eollet, this period was 29, 27, 
35, 9, 33, 27, 15, 42, 28, 17, 25, and 34 days respectively, which 
give a minimum of 9 days, a maximum of 42 days, and a mean of 
26 days. 1 This average is somewhat greater than that of the pri- 
mary infecting chancre, as deduced from clinical experience ; 2 but 
if, as Eollet claims ought to be done, we compare artificial inocula- 
tions with artificial inoculations, we find that the difference is very 
small. Thus, in Einecker's inoculation of an infecting chancre, the 
interval was 25 days; in Gilbert's, 24 days; and in Eollet's, 18 
days; making an average of 22 days. 

3. It is generally a papule, which in most cases becomes ulcerated 
and indurated, and is attended by engorgement of the neighboring 
lymphatic ganglia, and hence closely resembles a frequent form of the 
ordinary infecting chancre. — I must recall to the mind of the reader 
the fact that the chancre-type, as formerly received, originating in 
a pustule and consisting of an excavated ulcer with sharply-cut 
edges, is now known to belong to the chancroid ; and that, as proved 
by the observations of Bassereau and others, the infecting chancre 
is most frequently a superficial erosion, not extending beyond the 
epidermis or epithelium, and which, in many cases, becomes papu- 
lar, and is elevated above the surrounding surface; in a small 
proportion of cases only does it involve the whole thickness of the 
integument or mucous membrane. 

In nearly all the reported cases of syphilis following the inocu- 

1 Gaz. Med. de Lyon, Dec. 16, 1859, p. 567. 2 See p. 370. 



SECONDARY CONTAGION PRODUCES A CHANCRE. 491 

lation of a secondary symptom, the initial lesion is said to have 
been a papule, which was gradually developed into a tubercle, and 
(sometimes after an interval of several days) took on superficial 
ulceration, which, if not explicitly mentioned, is indicated by the 
description of such a scab as could only be formed by the- desicca- 
tion of lymph or pus. In one instance only — Gibert's fourth inocu- 
lation — do we find that there was no abrasion of the surface during 
the whole duration of the papule. Diday also refers to a case of 
secondary contagion from an infant to a nurse, in which a papular 
elevation upon the breast, which was followed by general syphilis, 
did not at any time ulcerate in the slightest degree. 1 

In the two cases of contagion from inoculation of the blood in 
performing vaccination, reported by M. Lecoq, the initial lesions 
were excavated ulcers, presenting exactly the same appearances as 
the so-called Hunterian chancre. 

Induration of the base of the sore and engorgement of the neigh- 
boring lymphatic ganglia, those two important symptoms of an 
infecting chancre, have been found in most of the initial lesions of 
syphilis from secondary symptoms, whether the result of artificial 
inoculation or infection by contact. Invariable constancy could 
not be expected, when they are transitory or absent even in some 
cases of primary sore. It should also be remembered that most 
artificial inoculations have been performed without any suspicion 
that a primary sore would be developed, and generally by persons 
who attached but little importance to induration, and who may 
therefore have overlooked it in cases in which it is not noted. If 
aware of its importance they would have distinctly mentioned its 
absence. Wallace's and Waller's cases are somewhat imperfectly 
reported, and yet we find induration of the initial lesion spoken of 
in two of the three cases pertaining to the former, and in one of 
the two cases of the latter. Each of these symptoms was present 
in Einecker's, and in both of Lecoq's cases. Of Gribert's three 
inoculations of secondary lesions and of the blood, the initial sore 
was indurated in two, and in the third, the patient was absent from 
observation at the usual time for its development ; the neighboring 
ganglia were engorged in all. I have .not been able to refer to a 
full account of the cases reported by the surgeon of the Palatinate. 

The testimony of those cases of secondary contagion not artifi- 
cially inoculated, which have been observed in practice, is still 

1 Traite de la Syphilis des Nouveau-nes, Paris, 1854, p. 295. 



492 GENERAL SYPHILIS. 

more conclusive. In those occurring in adults, recorded by Kollet 
and Fournier, induration of the base of the sore (with one excep- 
tion) and engorgement of the ganglia were present in all, and as 
fully developed as in the most perfect infecting chancre. Indura- 
tion of the axillary ganglia in nurses infected by syphilitic infants 
attracted attention many years ago. Diday says: "Nothing is 
more common than to see engorgement of the glands of the axilla 
in women contaminated through the medium of the breast. Mahon 1 
observed this fact, and laid it down as a general rule, which has 
proved true in the majority of cases which have come under my 
observation." 2 _ The same fact is noticed by Bosquillon 3 and other 
writers on infantile syphilis. 

4. The period of incubation of general symptoms is nearly the same 
whether the disease be derived from a primary or secondary lesion. — 
In the twelve cases collected by Kollet, this second incubation of 
the virus was 37, 26, 92, 42, 31, 128, 26, 107, 48, 37, 12, and 38 
days respectively ; making an average of 52 days, which will be 
reduced to 45 days, if the case be omitted in which the interval be- 
tween the appearance of the chancre and that of general symptoms 
was 128 days, and in which mercury was administered. It will be 
recollected that Diday's accurate investigations relative to the dura- 
tion of the same period after contagion from a primary sore give 
a mean of 46 days — a correspondence with the average duration 
after contagion from a secondary lesion, which is truly remarkable. 

5. The earliest general symptoms are of the same character after 
contagion from a secondary as from a primary lesion. — The truth 
of this proposition is evident upon examination of the cases which 
I have quoted, and in which the earliest general symptoms have 
been mucous patches, an erythematous or papular eruption, acne 

1 Histoire de la Medecine Clinique, suivie d'un Memoire sur la Nature et la 
Communication des Maladies Veneriennes des Femmes enceintes, des Enfants et 
des Nourrices. Paris, 1804, p. 440. 

2 Traite de la Syphilis des Nouveau-nes, p. 293. Diday proceeds to say that this 
engorgement by no means proves that the lesion upon which it depends is a pri- 
mary chancre. This was written, however, before Rollet's doctrine was known, 
and Diday has since modified his opinion, as appears from the following quotation 
of his words in a recent discussion before the Imperial Society of Medicine of Lyons, 
Feb. 20, 1860 : "Quel est done la nature de cet accident initial ? C'est un chancre, 
je Vadmets ; mais un chancre a caracteres effaces, mitiges, attenues." (Gaz. Med. de 
Lyon, No. 8, 1860, p. 209.) 

3 French translation of Bell on Venereal, vol. ii. p. 620, as quoted by Fournier. 



SECONDARY CONTAGION PRODUCES A CHANCRE. 493 

capitis, alopecia, post-cervical engorgement, etc., as after contagion 
from a primary sore. 

In reviewing the above comparison we find a general correspond- 
ence between the phenomena following contagion from primary 
and from secondary symptoms. In the latter the period of incuba- 
tion preceding the appearance of the initial lesion is perhaps longer 
than in the former, but our statistics are yet too meagre to render 
it absolutely certain, and a difference in this respect cannot at any 
rate be considered of much importance. 

The greatest difficulty lies in reconciling the aspect of the initial 
sores in the two cases ; for even with the modification of our views 
as to the characteristics of the chancre-type brought about by 
modern investigations, it must be confessed that the earliest lesion 
following secondary contagion differs in some respects from that 
which appears after primary; it is more frequently papular, is 
generally slow in taking on ulceration, and, in a few instances — if 
the statements of observers can be implicitly believed — is not 
moistened by the slightest secretion during its whole existence. 

But are these points of difference sufficient to induce us to make 
a distinction between syphilis derived from a primary and that 
from a secondary symptom, and to deny that the first effect of the 
virus is in both a chancre? I think not. The main features of 
the initial lesions in the two cases are the same ; the slight varia- 
tion may be accounted for by the seat selected for the artificial 
inoculations, which has always been either the arm or thigh ; and, 
as I have already stated in the present work, I believe that our 
ideas of the objective symptoms of a chancre have been by far too 
limited, and that it is unreasonable to expect invariable uniformity 
in its aspect. The ulcerated and indurated papule, attended by 
engorgement of the neighboring ganglia, which appears after 
inoculating the secretion of a constitutional manifestation of syphi- 
lis, cannot be ranked among secondary symptoms from which it is 
separated by a period of incubation ; it is evident that it can only 
be called primary, and I believe, with Langlebert, Eollet (whose 
line of argument has for the most part been followed in the present 
section), and Fournier, that it is fully entitled to the name of chancre. 
Eicord has as yet failed to express himself upon this subject, but 
the opinion of his pupil, M. Fournier, who is associated with him 
in the publication of his Lecons sur le Chancre, may be taken as 
an indication that he regards this new doctrine with favor, even if 
he does not yield it his full sanction. 



494 TREATMENT OF SYPHILIS, 



CHAPTER V. 

TREATMENT OF SYPHILIS. 

The opinion very generally prevails, that syphilis is a disease 
which, if left to itself, will always go on from bad to worse, attack 
in its progress the deeper and more important organs, and probably 
terminate in death. The correctness of this opinion, at least so far 
as concerns its invariability, may well be called in question, since 
syphilitic patients are rarely, if ever, allowed to go without treat- 
ment, and consequently little opportunity is afforded for observing 
the natural progress of the disease; and we cannot logically infer, 
because certain cases, in spite of remedies, pursue a disastrous 
course, that the same would have been true of others, which have 
terminated favorably, if the treatment had been less thorough, or 
had been altogether omitted. It would be more reasonable, though 
less flattering to ourselves, to conclude that as art has been com- 
paratively impotent in the former, it can claim for itself but a por- 
tion of the credit in the latter. 

I have had no unusual facilities for observing the natural course 
of syphilis, but several circumstances have led me to believe that, 
in many instances, under favorable circumstances, this disease tends 
to self-limitation. I have been struck with the fact that some pa- 
tients, who either through neglect or ignorance fail to pursue any 
continued course of treatment, still live in comparative comfort, 
and, after several attacks of general symptoms, extended through a 
number of years, are finally free from farther annoyance; the dis- 
ease probably remaining dormant in the system, but ceasing to 
betray itself by any external manifestation. But still stronger 
evidence of a tendency to self-limitation is found in many cases in 
which treatment is faithfully pursued, and in which the disease, 
under the best management on the part of the surgeon, and the 
utmost obedience of orders by the patient, repeatedly recurs for a 
time, and yet ultimately disappears, without our being able to 



TREATMENT OF SYPHILIS. 495 

attribute this happy termination to the accumulated effect or pro- 
longed use of remedies, which have failed to afford permanent 
relief in the earlier attacks. I have so often found this to be the 
case/ that I do not hesitate to assure patients when discouraged by 
the reappearance of symptoms which they supposed were cured, 
that the tendency to relapse will probably cease after a time, and 
leave them in the enjoyment of a fair state of health; although 
never, after treatment however prolonged, do I promise certain 
immunity for the future. I can recall to mind quite a number of 
patients whom I treated for constitutional syphilis eight or ten 
years ago, and whose disease repeatedly returned, and was appar- 
ently uncontrollable by medicine for a period of from one to three 
years, but who have since been exempt from farther, trouble, and 
some of whom have married, and become the fathers of healthy 
children; and I cannot honestly ascribe their present immunity 
wholly to the remedies employed, but in a measure to the fact that 
the activity of the disease has been exhausted. 1 

This belief in a tendency to self-limitation — or, as it may be 
called, spontaneous quiescence — of syphilis, derived from my own 
experience, coincides very nearly with that of Diday, which has 
but recently fallen under my notice. This surgeon's mode of prac- 
tice has afforded him a most excellent opportunity for deciding 
this point, since, in the great majority of syphilitic cases, he with- 
holds all treatment, unless compelled to its resort by the urgency 
of the symptoms. As the results of his experience since adopting 
this course, Diday remarks, in the first place, that he has been 
struck with the regular evolution and succession of syphilitic" 
phenomena, and afterwards goes on to say that, in most cases, 
the disease never passes beyond the secondary stage; that, after 
several successive attacks — as, for instance, of mucous patches, 
exanthematous or papular eruptions, etc. — the symptoms diminish 
in intensity; the virus appears to be eliminated by the natural 
powers of the system ; the tendency to fresh manifestations disap- 
pears, and a permanent and spontaneous cure is obtained. In a 
few persons, on the contrary, he has found the disease become more 
serious and more deeply rooted by time; hence, he admits two 
classes of cases, in one of which syphilis naturally decreases, and 

1 " That all the constitutional forms of syphilitic affections, if left to the unaided 
powers of nature, have a constant tendency to wear themselves out, I am fully 
convinced." (Egan, Syphilitic Diseases, p. 245.) 



496 TEEATMENT OF SYPHILIS. 

in the other increases in intensity; in the former, he resorts to 
hygienic measnres alone; in the latter, he employs specifics, but 
not to the neglect of hygiene. 1 

I do not propose, however, to recommend such an expectant 
course of treatment for syphilis, for we have as yet too little evi- 
dence of its safety. He would be a bold man who should attempt 
it out of France, in opposition to the opinion of the whole profes- 
sion throughout the world with a few rare exceptions. Moreover, 
even admitting that syphilis will often cease spontaneously with the 
lapse of time, I firmly believe that it should receive active treat- 
ment, both for the good of the patient and the safety of society ; 
for the former, that he may escape injury to important organs, and 
avoid the ignominy which would result from his misdeeds being 
betrayed to the world ; for the latter, that the sources of contagion 
may be dried up, and the extension of the disease prevented. At 
the same time, if the idea which I have advanced with regard to 
the spontaneous quiescence of syphilis in many cases, be correct, it 
is not without a practical application of such importance, that I 
have desired to give it a prominent position at the commencement 
of this chapter upon treatment, where it has not been out of place 
to consider what the natural termination of the disease would be 
without the intervention of art. 

Experience has long since shown that specific remedies, in order 
to be of any avail, must not be pushed to the detriment of the 
general health or be administered at all when the system is 
greatly depressed, otherwise the disease will acquire a firmer hold, 
and the patient's condition be rendered worse instead of better ; 
yet in spite of this lesson, in undertaking the treatment of a case, 
the surgeon finds it a difficult matter to refrain from administering 
mercurials, provided he believes that these alone are capable of 
eradicating the disease; but if convinced that nature is not alto- 
gether powerless to eliminate the virus, he can wait patiently until 
the general health has been improved, satisfied that any delay which 
will give the vital powers a better chance to act, will not be time 
wasted. Again, who has not been disappointed and chagrined at 
the return of syphilitic symptoms after the most thorough course 
of treatment? But may it not be that nature is still carrying on 
the work of cure, which will be brought to a happy conclusion at 

1 Nouvelles Doctrines sur la Syphilis, p. 302 et seq. 



HYGIENE. 497 

a time winch art can no more hasten than it can arrest the progress 
of an eruption of variola or scarlatina ? In short, I am not willing 
to acknowledge, especially with the evidence existing to the contrary, 
that the vital powers afford a certain amount of protection against 
all other known diseases, but are impotent against the ravages of 
syphilis ; and a proper appreciation of these views will not render 
the surgeon inactive, but will, by holding out a better hope of suc- 
cess, induce increased efforts. 

The treatment of early general symptoms and of the infecting 
chancre is the same. The latter as well as the former, according 
to the views which have been advocated in this work, is an effect of 
the contamination of the blood by the syphilitic virus, although in 
the mysterious order of nature the two are separated by an interval 
of time which justifies the distinctive appellations of primary and 
secondar}^. So soon, therefore, as an infecting chancre can be 
recognized by the induration of its base and the engorgement of 
the neighboring lymphatic ganglia, the syphilitic diathesis is to 
be regarded as already established, and appropriate remedies are 
to be employed for as long a time and with as much care, as if 
secondary manifestations had appeared. 

Hygiene. — The successful management of any case of constitu- 
tional syphilis undoubtedly depends in a great measure upon 
attention to hygiene. The most careful administration of specific 
remedies will be of little avail, unless the patient be willing to 
submit to the necessary restrictions with regard to diet, exercise, 
exposure, etc. Many syphilitic patients who enter our hospitals 
begin to improve at once, simply from the fact that they are brought 
under better hygienic influences, and are obliged to lead a regular 
course of life and abstain from excesses which have hitherto de- 
pressed the vital powers and thwarted all attempts of nature or of 
art to eliminate the virus from the system. Yet, admitting the full 
force of this truth, it is impossible to give minute directions which 
will be applicable to all cases, when the circumstances in which 
different persons are placed are so various, and where so much 
must necessarily be left to the judgment of the surgeon. 

Supposing the daily life of a patient to be completely under our 

control, and that his general health is in a good condition, our 

directions will be somewhat as follows: "You must for a time make 

it your chief business to get rid of your disease. All other objects 

32 



498 TREATMENT OF SYPHILIS. 

which conflict with this are to be laid aside. The more exclusively 
you devote yourself to this purpose the better will be your chances 
of regaining and retaining your health. Your habits must in all 
respects be systematic and regular, especially as regards your meals, 
sleep, and exercise. Excesses of all kinds must be scrupulously 
avoided. You are not to indulge in stimulants, tobacco, or coitus. 
Your food is to be of the very simplest kind, consisting only of 
stale bread or toast, and other farinaceous articles, with a small 
quantity of butter; water, milk, or weak black tea for your only 
drink; fresh meat or fish, sparingly, once a day; boiled potatoes, 
and a moderate amount of fruit in its season; and you are to 
leave the table as soon as you feel that your appetite is satisfied. 
Take daily exercise out' of doors, but do not carry it to fatigue. 
Guard against sudden changes of temperature, the extremes of heat 
and cold, wet, and exposure to a damp, chilly atmosphere. Let 
your room be well ventilated. Wear flannel next your skin, and 
change it frequently. Take a hot bath two or three times a week 
at night before going to bed. See that your bowels are open every 
day. Employ your mind in reading, or seek the society of a few 
friends who will not interfere in any way with your carrying out 
these directions; and let your thoughts dwell as little as possible 
upon your disease." 

It is evident that the calls of business will often interfere with 
the full execution of this programme, but the cases are rare in 
which it cannot be carried out in its more important details ; and 
if this can be done, there is no objection but rather an advantage 
in occupying a portion of the day in some quiet employment 
which will divert the patient's thoughts from himself and his 
disease. We must remember, however, that increased activity of 
life demands a greater supply of nourishment, and a more liberal 
diet than the one proposed will often be required especially for 
laboring men. 

If at any time while pursuing this regimen the patient's strength 
appears to flag, and he becomes debilitated and loses his appetite, 
greater freedom must be allowed him, and such changes be made 
in his diet as will readily suggest themselves to the surgeon ; since 
although it is desirable to keep the general condition a little below 
the full standard of health, anything like depression of the system 
must be carefully avoided. 

Attention to hygienic measures, similar to those here recom- 



HYGIENE. 499 

mended, has been recognized as of great importance by nearly 
every surgeon who has written upon the treatment of syphilis, and 
plays an important part in certain methods for which rules have 
been laid down with mathematical exactness ; as in the so-called 
hunger, and the mercurial cure, the treatment by Zittman's decoc- 
tion, and the dry treatment of the Arabians. 1 It is not desirable, 
however, to adopt any invariable routine, in which the varying 
condition of the system in different cases shall be ignored, and the 
exercise of the judgment be set aside ; and which shall render the 
duties of surgeon and patient almost automatic. No such labor- 
saving system can succeed in the treatment of syphilis. Bach 
individual case is a problem by itself the conditions of which are 
ever changing, and requiring the constant exercise of watchfulness 
and judgment. 

The essential features of the hygienic plan here proposed, and 
which I have long adopted in my own practice, are general regu- 
larity of life, simple diet, abstinence from stimulants, and attention 
to the functions of the skin and bowels ; and these may be carried 
out to advantage even in case the patient be debilitated by dissipa- 
tion, long continuance of the disease, or other causes. This is a 
point which I desire to have distinctly understood, since nothing 
could be farther from my thoughts than the idea that it is ever 
necessary or desirable to depress the system in order to effect a 
cure of syphilis. On the contrary, the general health, whenever 
below the normal standard, should be raised by every means in 
our power which will give it a real and not fictitious improvement ; 
and it is often necessary to administer the vegetable tonics, qui- 
nine, iron, or cod-liver oil, at the same time with specific remedies, 
and sometimes entirely to omit the latter until the system has been 
brought into a proper condition to bear them. Even with those 
who have been long addicted to intemperance, the means indicated 
will usually be sufficient to supply the place of their daily pota- 

1 The dry treatment of the Arabians, as communicated by an Arab physician 
who visited Marseilles, is described by M. Benoit, who has tried it with very 
satisfactory results, as have also Lallemand, Broussonnet, L. Boyer, Tribes, 
Jaumes, and Malinowski. The patient is directed to abstain from his usual 
articles of food ; lives on biscuit, dried almonds, figs, and raisins ; takes for his 
only drink in the twenty-four hours a glass or two of a decoction of sarsaparilla ; 
and a mercurial pill morning and evening. Gaz. Hebdomadaire, May 4, 1860, 
from the Montpellier Medical, 1860, Nos. 1 and 2. 



500 TREATMENT OF SYPHILIS. 

tions, though in rare instances it is necessary to allow a small 
quantity of wine, ale, or brandy to be taken with the meals. 

It is an interesting fact that important truths are sometimes 
arrived at by the simple observation of men entirely destitute 
of medical knowledge. The "sporting papers of the day," prior 
to the recent trial of strength and skill between the "Champion of 
England " and the " Champion of America," recorded the fact that 
the latter was afflicted with " a constitutional disease of the worst 
type," which was no other than syphilis, and which was kept down 
by generous living, but was always developed by the hardships 
incident to training for the prize-ring. 

The chief remedies employed in the treatment of syphilis are 
mercurials, and iodine and its compounds. The former exert their 
therapeutic action mainly upon secondary and the latter upon ter- 
tiary symptoms, so that the susceptibility of a given lesion to one 
or the other will indicate to which stage of syphilis it belongs. 
This rule, however, is not so invariable as the above statement 
would make it appear, and requires explanation. 

There is no distinct line of demarcation in respect to treatment 
between secondary and tertiary lesions, but a gradual transition 
from one to the other. By far the most powerful agent in the 
treatment of the indurated chancre and the earlier general symp- 
toms is mercury ; as the disease progresses, iodine gradually begins 
to exercise a therapeutic influence ; those symptoms which border 
upon the boundary line between secondary and tertiary manifesta- 
tions, and which constitute the stage of transition — so-called by 
Kicord — require a combination of mercury and iodine ; finally ter- 
tiary symptoms yield with great facility to iodine and with difficulty 
to mercury, though it is very doubtful whether the former agent 
without the assistance of the latter, can effect their permanent re- 
moval. 

Mercurials. — Mercury came into general use in the treatment 
of syphilis within fifty years after the appearance of the Italian epi- 
demic, 1 and, in spite of the many attempts which have been made 
to supplant it by other remedies, still holds its ground as the only 
reliable agent for combating secondary lesions. At the present 

1 H.ESER (Historisch-Pathologische Untersuchungen, vol. i. p. 230), according 
to Virchow, quotes a satirical poem composed by Georgius Summaripa, of Verona, 
in 1496, in which the use of mercury in syphilis is mentioned. 



MERCURIALS. 501 

day its efficacy is admitted both by regular and irregular practi- 
tioners, though the latter generally administer it furtively and under 
the guise of some other name. It is the active ingredient of most 
of the "life-balsams" and "essences of sarsaparilla," the marvellous 
virtues of which for the cure of "private diseases" are proclaimed in 
our daily and weekly journals (religious as well as secular). The 
elastic principle of " similia similibus " is also made to cover it ; the 
more conservative Homoeopaths giving it (generally in the form of 
the protiodide) in the doses prescribed by the U. S. Pharmacopoeia, 
and even the extremists not trusting to the "dynamic action" of 
high potencies, but employing the first trituration (one part to 
ninety-nine of sugar of milk), put up in bottles carefully coated 
with black paper to protect it from the action of the light. 

No one form of mercury can be used exclusively in all cases 
and in all stages of the disease. A preparation which agrees with 
one person will not unfrequently disagree with another, and it is 
sometimes necessary to make a trial of several before the one best 
adapted to the case can be selected. Again, after employing one 
form for a time, when the system has become accustomed to it, it 
is often desirable to change to another ; in this manner the thera- 
peutic action may be increased without resorting to large doses, 
which are liable to disarrange the bowels. 

When administering mercurials for an indurated chancre, which 
it is desirable to heal as soon as possible either to avoid communi- 
cating it to others, or to remove the inconvenience of the local sore, 
or when commencing the treatment of general symptoms which are 
of such a character as to confine the patient to the house, or which 
are liable to expose him to his associates, some preparation should 
be selected, as the blue mass, calomel, or gray powder, which will 
most speedily affect the system. At first, however, mercury should 
be given very cautiously, and in small and infrequent doses, since 
the patient's susceptibility is generally not known before trial, and 
salivation should be carefully avoided. Contrary to a very general 
but mistaken idea, at least as applied to the treatment of syphilis, 
the mouth is much more readily affected by the first mercurial 
course than ever afterwards; hence particular caution should be 
exercised at this time. Analysis of the blood of persons with 

1 I was recently treating a case of syphilitic iritis with half a grain of the pro- 
tiodide three times a day, when a friend of the patient, a distinguished homoeopath 
of this city, advised him to take the same quantity four times a day. 



502 TKEATMENT OF SYPHILIS. 

infecting chancres has shown it to be deficient in corpuscles, and to 
contain an excess of albumen, and at the time of the appearance of 
secondary manifestations, marked symptoms of chloro-ansemia are 
often present; hence it is desirable to associate a tonic with the 
mercurial, as in the following formula : — 

Pp. Pilulse hydrargyri ^ij. 

Ferri sulphatis exsiccati £)j. 

Extracti opii gr. v. 
Mix and divide into twenty pills. 

Pp. Hydrargyri cum creta £)ij. 

Quinise sulphatis £)j. 
Mix and divide into twenty pills. 

I have been led by observation to believe that the addition of 
quinine renders mercury less liable to salivate, and thus serves a 
double purpose. 

When there is special reason for desiring speedy mercurial action, 
a combination of several preparations may effect the purpose sooner 
than one alone. 

Pp. Pilulse hydrargyri [)j. 

Hydrargyri chloridi mitis gr. x. 

Hydrargyri cum creta 9j. 

Ext. opii gr. v. 
M. In twenty pills. 

It is best to commence with one of the above pills morning and 
night, and, if no effect be perceptible by the fourth or fifth day, to 
increase to three a day. So soon as the chancre begins to assume 
a more healthy aspect, or the secondary symptoms to subside, no 
farther change in the treatment is required, unless, on the one hand, 
the mouth become tender, or, on the other, the symptoms cease to 
improve ; in the former case the remedy must be suspended, and 
in the latter increased. 

Except under the circumstances above indicated, I decidedly 
prefer and in my own practice commonly employ one of the iodides 
or the bichloride of mercury in the treatment of secondary symp- 
toms. 

The dose of the protiodide is half a grain, which is to be given 
in a pilular form two or three times a day. I sometimes increase 
the dose to two grains in the twenty -four hours, but have never 
derived any benefit from exceeding this quantity, which alone is 
apt to produce diarrhoea. Indeed, the chief objection to this pre- 



MERCURIALS. 503 

paration is the abdominal pain and intestinal irritation which it 
often occasions ; but these may in most cases be avoided by direct- 
ing the patient to take his pill about an hour after meals, when the 
stomach is not entirely empty, or, if necessary, by the addition of 
opinm ; if these measures fail, some other form of the mineral must 
be employed. The sugar-coated granules of the protiodide, pre- 
pared by Garnier, Lamoureux, and Co., each of which contains 
one -fifth of a grain, afford a very convenient and elegant mode of 
administration, and, by their minute division, enable the surgeon 
to graduate the dose from day to day according to the exigencies 
of the case. 

The protiodide is Kicord's favorite form of mercury, and has 
acquired a wide-spread and well-deserved reputation. Sigmund, 1 
however, whose extensive experience entitles his opinion to con- 
sideration, speaks disparagingly of it on account of its tendency to 
produce diarrhoea, and thinks it of little value except in papular 
and pustular syphilitic eruptions, and even then inferior to some 
other forms of mercury. 

A convenient mode of exhibiting the biniodide of mercury is by 
decomposing the bichloride by means of the iodide of potassium, 
and dissolving the precipitated biniodide with an excess of the 
iodide of potassium, as in the following formula. 

I£. Hydrargyri bichloridi gr. ij. 

Potassii iodidi 3ss. 

Aquae §viij. 
M. 
.Dose. — A dessertspoonful an hour after eating, two. or three times a day. 

Gibert's favorite formula, which is much employed at the Saint 
Louis and other hospitals of Paris, where it is known as the "syrup 
of the ioduretted biniodide of mercury," is as follows : — 

^. Hydrargyri biniodidi gr. j. 
Potassii iodidi 9ijss. 
Aquae 5j. 

Filter through paper and add — 
Syrupi g v. 
M. 
Dose. — A tablespoonful. 

Such combinations of mercury and iodide of potassium are the 
more valuable, the longer the time which has elapsed since con- 
tagion. In late secondary lesions, I often administer a grain of the 

1 Wien Wochenschrift, 1859, No. 39. 



504: TREATMENT OF SYPHILIS. 

protiodide of mercury at noon and the iodide of potassium morning 
and night. 

But above all other preparations of mercury, the bichloride 
commends itself from its slight tendency to produce salivation, the 
tolerance with which it is borne by the system, the safety with 
which it may be continued for a long period, and the satisfactory 
results which follow its administration ; it is, therefore, especially 
worthy of employment in patients living at a distance from their 
surgical attendant ; in those who are peculiarly susceptible to the 
morbid action of mercury, in persons of a broken-down constitution, 
and in all cases in which it is necessary greatly to prolong the use 
of remedies either for the relief of existing symptoms or as a pro- 
phylactic against future attacks. In my own practice in most cases 
of secondary symptoms in which I do not employ the bichloride 
from the first, I resort to it after using one of the iodides, and 
continue it for a number of months. 

The bichloride of mercury may be administered in solution or 
in a pill. It is very liable to undergo decomposition, and, with the 
intention of preventing this, is usually associated with muriate of 
ammonia. The average dose for an adult is one-sixteenth of a 
grain, but is sometimes raised to a fourth or even half a grain ; 
in the treatment of syphilis, however, I have rarely found it bene- 
ficial to exceed one-eighth or one-sixth of a grain, given three times 
a day upon a stomach not entirely empty ; even in this quantity it 
is difficult to prevent intestinal pain and irritation. 

This preparation of mercury was extensively used by Yan 
Swieten, 1 and is the active ingredient of the "liquid" known by 
his name, the formula for which is as follows : — 

J£. Hydrargyri bichloridi 1 pt. 
Aquae 900 pts. 
Spiriti rect. 100 pts. 

The average dose of Yan Swieten's liquid is a tablespoonful, 
which is given in a glass of sweetened water. 

The solubility of the bichloride of mercury in alcohol and water 
facilitates its administration in any of the vegetable tinctures and 
infusions which are often required in anaemic subjects. When 
given in this form, it doubtless undergoes partial decomposition, 
but does not appear to lose its therapeutic effect. I frequently 
employ as a menstruum the tincture of the chloride of iron. 

1 Commentaries, xvii. 292. 



FUMIGATIONS. 505 

I£. Hydrargyri bichloridi, 

Ammonise muriatis, aa gr. iij. 
Tinct. cinchonse comp. 5 iij. 
Aqua3 ^iij. 
M. 
From a teaspoonful to a tablespoonful two or three times a day. 

fy. Hydrargyri bichloridi gr. iv. 

Tinct. ferri chloridi 3iv. 
M. 
Eight drops contain very nearly one-sixteenth of a grain of the bichloride. 

The pilular form is more convenient for many persons. Equal 
parts of the bichloride of mercury and the muriate of ammonia 
may be dissolved in a very small amount of pure water, with which 
finely -powdered cracker is to be mixed in sufficient quantity to ab- 
sorb it ; syrup of gum acacia is added to give it consistency, and 
the mass rolled into pills containing the desired quantity of the 
bichloride. Extract of dandelion is also a convenient vehicle, but 
is more liable to decompose the mercurial. 

It is a fact but little known that the bichloride may be adminis- 
tered in cod-liver oil by first dissolving it in a few drops of sul- 
phuric ether. If the bottle be kept tightly corked it may be 
retained in solution for an indefinite time : but if the ether be allowed 
to evaporate by exposure to the air, the bichloride will be precipi- 
tated and cannot be redissolved by the addition of more ether. 

I£. Hydrargyri bichloridi gr. ij. 
Etheris sulphurici 5J- 
Dissolve and add — 
Olei morrhuse ^vj. 
M. 
A dessertspoonful contains one-twelfth of a grain of the bichloride. 

The preparations of mercury above mentioned are those which 
are found to be the most serviceable in the treatment of syphilis, 
though others, as, for instance, Plummer's pill or mercury with 
chalk, may sometimes be employed to advantage ; the latter is Mr. 
Acton's favorite remedy, given in doses of five grains three times 
a day. Montanier states that the acetate of mercury has sometimes 
proved successful when other preparations have failed. 1 

Fumigations. — Mercurial fumigations, although employed from a 
very early period in the history of syphilis, never acquired much 

1 Gaz. dea Hopitaux, No. 19, 1856. 



506 TREATMENT OF SYPHILIS. 

reputation until of late years, since they have been strongly recom- 
mended by Mr. Langston Parker, of Birmingham, Eng., who con- 
siders the treatment of syphilis by this method as " safer, quicker, 
more certain, less frequently followed by relapses, and more efficient 
in obstinate cases" than by any other. I have had considerable 
experience in the use of mercurial fumigations, and although I am 
not prepared to indorse to their full extent the encomiums which 
Mr. Parker bestows upon them, yet I believe them to be a very 
valuable mode of treatment in some cases, and one which I should 
be quite unwilling to dispense with. 

In most of our large cities 1 men are to be found who make a 
business of administering these baths, and whom the surgeon, when 
within their reach, will find it most convenient to employ ; but the 
necessary apparatus can be manufactured by mechanics such as 
may be found in nearly every village. A light frame, sufficiently 
large to inclose the patient when seated upon an ordinary chair, is 
to be made of strips of wood and covered with oilcloth lined with 
flannel. A door in front serves for ingress and egress; and there 
should be a circular opening upon one side, to which is attached a 
cloth funnel projecting inwards, into which the patient may insert 
his head for the purpose of gaining fresh air if the mercurial fumes 
become oppressive. A small trap-door near the floor enables the 
attendant to superintend the evaporation of the mercury which is 
placed within the inclosure upon a metal plate supported by a tri- 
pod with a spirit-lamp beneath. Steam, which is an indispensable 
requisite of Mr. Parker's method, may be generated from a metallic 
basin containing water heated by a second spirit-lamp beneath the 
patient's chair, but a more copious and rapid supply is required 
than can readily be obtained in this manner, and it is better to 
have a boiler, easily made by any tinsmith, without the framework, 
and connecting with it by means of a tube of tin or India rubber ; 
a shallow vessel beneath, holding alcohol, will afford a broad volume 
of flame and produce a large quantity of steam. The mercurial 
vapor may be generated from metallic mercury, but preferably 
from calomel, the gray oxide, or the binoxide, from one to three 
drachms of which are required for each bath. 

The patient of course divests himself of his clothing, and any 

' In New York, Mr. Cohen, at the Fifth Avenue Hotel building, corner of 24th 
Street and Broadway, deservedly enjoys the confidence of the profession. 



FUMIGATIONS. 507 

gold ornaments worn upon the person should be removed to pre- 
vent their being coated with an amalgam of mercury. The effect 
of the bath is increased when the head is immersed and the vapor 
inhaled, especially in affections of the mouth, throat, or nose. As 
soon as the patient is seated in the chair, the spirit-lamp beneath 
the mercurial is lighted and steam let on from the boiler. In the 
course of a few moments profuse perspiration is induced, when it 
is better to shut off or slacken the steam until within five or ten 
minutes of the termination of the bath; for if continued in full 
force it is apt to debilitate the patient. The whole bath occupies 
about twenty minutes or half an hour. The patient is allowed to 
cool gradually, and is rubbed thoroughly dry with a towel, and Mr. 
Parker recommends that he should drink a cupful of warm decoc- 
tion of guaiacum or sarsaparilla immediately afterwards. 

The baths may be repeated two or three times a week, their fre- 
quency being determined by the strength of the patient, and the 
effect produced. During their administration, the patient should 
wear flannel next the skin, should observe the rules with regard to 
diet, etc., heretofore laid down, and mercury in minute doses or 
iodide of potassium may be given internally. Salivation is rarely 
induced, though the gums often become tender. Two or three 
repetitions generally produce a sensible effect upon the symptoms, 
which rapidly disappear under a continuance of the fumigations. 
From twelve to twenty baths in all are usually sufficient. 

I am not in the habit of resorting to moist mercurial fumiga- 
tions, except in inveterate cases of syphilis, or when the internal 
use of mercury cannot be supported ; and under these circumstances 
they are extremely valuable. Cases, in which mercurials by the 
mouth, though carefully guarded by opium, cannot be pushed to 
such an extent as to subdue the existing symptoms, without excit- 
ing an undue amount of intestinal irritation or salivation, and those 
cases in which the disease has repeatedly returned after being ap- 
parently cured, are better treated by this method than by any 
other with which I am familiar, except, perhaps, by inunction. 
Still, relapses will occur as after other modes of treatment, and I 
have not found that degree of security for the future which appears 
to have been obtained in Mr. Parker's own practice. 

The greatest objection to mercurial fumigations is their liability 
to produce headache and debility. I have endeavored to obviate 
this difficulty, by diminishing the amount of steam, and shortening 



508 TREATMENT OF SYPHILIS. 

the duration of the baths, but with only partial success. Some 
patients suffer so much in this way, that it is necessary to suspend, 
or entirely abandon the treatment, and, in most cases, considerable 
care is required to avoid unpleasant effects. If the patient become 
debilitated, his diet should be more nourishing, and he may be 
allowed a small quantity of wine with his meals. 

It is well to remind the reader that mercurial fumigations should 
not be given in an apartment which is used as a sitting or bed- 
room; and that free ventilation should be resorted to after each 
bath, otherwise the atmosphere, walls, furniture, etc., may become 
so saturated with mercury, as to exert an injurious influence both 
upon the patient and attendant. 

Inunction. — The treatment of syphilis by mercurial inunction 
is attended with rather more inconvenience than other methods, 
and is, therefore, not generally employed, although in the opinion 
of many, and especially the German physicians, it is held in high 
esteem. Sigmund, for instance, who used mercurial inunctions in 
9,379 cases, occurring at the Vienna Hospital between the years 
1842 and 1855, states that this is the simplest and most efficacious 
mode of treating the various forms of syphilis. 1 The manner of 
employing mercurial inunction is as follows. 

The warm weather of spring, or the beginning of summer, is 
best adapted for the purpose. The patient should be prepared by 
taking several warm baths, in order to render the skin clean and 
soft. The frictions are to be made upon the inner surfaces of the 
thighs, arms, and axillas, which are to be used alternately, so as 
to avoid irritation or abrasion of any one part. The evening, 
before retiring, is the most favorable time of day, when from a 
scruple to a drachm of strong mercurial ointment is to be rubbed 
for ten or twenty minutes upon the part selected, as, for instance, 
the inner surfaces of the thighs ; if by an attendant, his hand should 
be covered with a soft leather glove, previously soaked in fat, to 
prevent its absorbing the ointment ; the parts are then to be covered 
with flannel for the night ; the remains of the ointment are washed 
off in the morning with warm soap and water, after which Sigmund 
advises that perspiration should be promoted, for two or three 
hours, by wrapping the patient closely in blankets. The whole 

1 Medical Times and Gazette, May 2, 1857; from the Wien Wochenschrift, 1856, 
No. 36. 



INUNCTION. 509 

day, with the exception of five or six hours, is thus spent in bed, or 
under warm coverings in the bed-room. The clothes and bed- 
linen should be frequently changed, and the apartments be well- 
ventilated ; but care should be taken to prevent the patient from 
being chilled. The diet should be of the simplest kind, and tobacco 
and alcoholic stimulants forbidden, though anemic patients may be 
allowed a little wine or beer with their dinner. Sigmund states 
that he has rarely found it necessary to resort to more than forty 
frictions in all — counting one to each day — and that twenty or 
thirty usually suffice. In weak subjects it is sometimes desirable 
to suspend the frictions for a week or fortnight, once or twice in 
the course of the treatment ; and excessive debility, inordinate per- 
spiration or salivation may, though rarely, require the entire aban- 
donment of this method. 

In my own practice, I have rarely been able to carry out the 
above treatment so methodically as Sigmund recommends, but I 
frequently resort to mercurial inunction, without the sweating 
process and the confinement to the house, and have been very 
much pleased with the results. Whenever a patient, undergoing 
a mercurial course, suffers from diarrhoea which opium will not 
check, or complains that he has lost his appetite and strength or 
that all food tastes alike, the substitution of tonics for the mercurial 
internally and the employment of inunction externally, will gener- 
ally produce a most satisfactory change in his feelings, and act 
equally well upon his syphilitic symptoms. In infantile syphilis 
by far the best mode of employing mercurials is by inunction. 

The older writers on venereal advised that mercurial inunction 
should not be performed over a serous cavity, as upon the abdo- 
men or thorax, and not without reason, if we can believe the fol- 
lowing case reported by Bassereau: — 1 

11 1 once made the autopsy of a woman who died of acute peritonitis, 
and who had been treated for five days with copious mercurial inunction 
upon the abdomen. On opening the body, I found in the peritoneal 
cavity, between the uterus and rectum, nearly a teaspoonful of metallic 
mercury. I think I have read of similar cases. If the woman had not 
died of peritonitis, what would have become of the mercury which had 
thus filtered through the skin and abdominal muscles V 

What shall we think of this case? In itself, it appears incredi- 

1 Affections de la Peau, etc., p. 518. 



510 TREATMENT OF SYPHILIS. 

ble ; yet Bassereau was a keen observer, and a man of unimpeach- 
able honesty. Let the reader decide. 

Before commencing treatment for constitutional syphilis, a pa- 
tient is often weighed down with languor and general malaise, 
which are the effect of his disease; under the use of remedies, his 
strength and spirits improve, and he becomes light, active, and 
buoyant; after continuing treatment for some time, however, it is 
frequently the case, that although his symptoms have constantly 
improved, he is again subject to depression, but if questioned as to 
the cause or nature of his feelings, can give no satisfactory reply; 
his low spirits and uncomfortable sensations cannot be denned or 
explained, but are none the less real. This condition is unques- 
tionably due to the influence of mercury, since I have always 
found it yield to a suspension of specific remedies, whether aided 
or not by a cathartic, and a change of air and scene for a few days, 
when this is practicable. Bearing in mind this effect of mercury, 
I believe that the combination of opium with the mercurial, which 
is commonly adopted, is not only serviceable in restraining action 
upon the bowels, but also in diminishing the sensibility of the 
nervous system, and enabling it better to support the continued 
use of specific remedies. 

Salivation. — The most frequent unpleasant effect of the adminis- 
tration of mercurials, and the one which it is especially necessary 
to guard against, is salivation, though this formerly was thought 
to be a desirable result of treatment, and to favor the cure of 
syphilis. The therapeutic effect of mercury undoubtedly precedes 
its morbid action, although the two are often separated by a short 
interval only, and sometimes appear to be synchronous. If we 
carefully observe the phenomena which ensue after commencing a 
mercurial course, selecting by preference a case which has as yet re- 
ceived no treatment, and in which the effects of mercury are gener- 
ally most clearly marked, they are usually found to be as follows : 
for the first few days, no improvement is perceptible in the symp- 
toms, which may even become aggravated ; the chancre may spread 
over a larger extent of surface, or new secondary lesions may ap- 
pear ; suddenly, however, the primary sore begins to assume a more 
healthy aspect, and the process of cicatrization to advance from its 
circumference towards the centre; the indurated base and neigh- 
boring lymphatic ganglia lose somewhat of their hard and cartilag- 
inous feel ; or the syphilitic eruption commences to fade away. If 



SALIVATION. 511 

now the mercurial be continued, even though the quantity admin- 
istered be not increased, tenderness of the mouth rarely fails to 
appear in the course of a very few days, and frequently as soon as 
the second or third day after the first improvement was noticed in 
the symptoms. In a few instances only does an amelioration in 
the symptoms appear 'to coincide with decided salivation, and in 
such cases the action of the mercurial has generally been so rapid, 
that an interval between the two may readily have been overlooked. 
Again, if mercury be continued after salivation has taken place, its 
therapeutic action is not increased, but, in most cases, on the con- 
trary, the symptoms are aggravated. The practical inference from 
the above remarks is, that the specific treatment of syphilis may 
be carried to tenderness of the gums, in order to afford assurance 
that its full therapeutic effect has been obtained, but that it should 
not intentionally be pushed to complete salivation, and never in 
any case be continued beyond this point. 

I have already called attention to the fact that a patient is much 
more liable to be salivated by the first than by any subsequent 
course of mercury ; the system becoming tolerant of its presence by 
repeated use. This fact has been so evident in my own practice, 
that I am surprised that it has not attracted more attention, although 
it has been by no means unnoticed by other writers. A remark- 
able instance has recently been under my observation. A gentle- 
man applied to me with syphilitic roseola, for which I prescribed 
mercurials, which caused the disappearance of the eruption in the 
course of ten days, but which gave him so sore a mouth that I dis- 
continued the remedy, intending to resume it again in a short time. 
Several circumstances occasioned delay, when, in about three weeks, 
a papular eruption appeared in patches, which became covered with 
scales. I immediately resumed treatment, but found the greatest 
difficulty in producing the slightest effect either upon the symp- 
toms or upon the gums, and it was only after the lapse of six weeks, 
and a trial of various mercurial preparations, and different modes 
of administering them, including fumigation, that the mouth was 
a second time affected, and the symptoms improved. Patients who 
have supposed themselves extremely sensitive to the action of mer- 
cury, founding their opinion upon past experience, are often sur- 
prised at the large amount which they are able to take, not only 
with impunity, but with decided benefit to their symptoms and 



512 TREATMENT OF SYPHILIS. 

their general condition, while under treatment for constitutional 
syphilis. 

The earliest indication of the morbid action of mercury upon the 
mouth ; which is likely to attract the patient's notice, is tenderness 
of the gums ; this is soonest felt just back of the superior incisor 
teeth, and in the lower jaw, posterior to the last molars. I always 
warn patients of these symptoms at the commencement of a mer- 
curial course, and direct them immediately upon their appearance 
to suspend treatment until they can see me. This precaution is 
desirable, although it sometimes leads timid persons to imagine the 
mouth affected long before this result has actually taken place. I 
have met with several instances in which the soreness attendant 
upon the development of a wisdom tooth has been mistaken for 
mercurial salivation, and various other causes may also produce 
tenderness of the gums, and a fetid breath. It is, therefore, always 
desirable for the surgeon carefully to inspect the mouth before 
commencing treatment, in order that he may be able to determine, 
at a subsequent period, how far to attribute its unhealthy condition 
to the influence of mercury. 

Other prominent symptoms of mercurial stomatitis are a metallic 
taste in the mouth ; a fetid odor of the breath — which, however, is 
not characteristic, since it may be perfectly simulated by the offen- 
sive smell proceeding from a want of cleanliness, or gums diseased 
from other causes ; an increased flow of saliva ; a sensation as if the 
teeth were elongated, and tenderness when they are struck together ; 
swelling of the tongue, which bears the impress of the teeth upon 
its sides ; tumefaction of the mucous membrane of the gums, cheeks, 
and lips ; difficulty in talking and swallowing ; enlargement of the 
neighboring ganglia; sometimes general febrile disturbance and 
great nervous irritability ; in extreme cases ulceration of the soft 
parts, which may perforate the cheeks ; loosening and detachment 
of the teeth; and even caries of the alveoli and of the maxillary 
bones. 

Under the cautious method of administering mercury which is 
now adopted, excessive salivation is rarely induced, and, even when 
left to itself, usually subsides in the course of a week or ten days 
after the suspension of treatment. Much, however, may be done 
to shorten its duration and alleviate the sufferings of the patient. 
The bowels, if confined, should be freely purged, and the action of 
the skin promoted by warm baths and underclothes of flannel. 



SALIVATION". 513 

The most distressing symptoms are the great difficulty in swallow- 
ing, nervous excitability, and inability to sleep. Nourishment 
should, therefore, be administered in a liquid and concentrated 
form, as strong beef-tea 1 ; and rest be secured by the exhibition of 
Dover's powder, aided by a hot mustard pediluvium at night, which 
will also act as a derivative from the head. Half an ounce or an 
ounce of Labarraque's solution of chlorinated soda in half a pint 
of water forms an excellent gargle for such cases. 

Although the above measures should by no means be neglected, 
the most direct and effectual treatment of salivation consists in the 
administration of the chlorate of potash. I usually order a few 
drachms or an ounce of this salt in powder, and direct the patient 
to dissolve from one to two teaspoonfuls in a pint of water, milk 
and water, flaxseed tea, decoction of marshmallow, or in whatever 
other vehicle may be most agreeable. This solution is to be used 
warm, and is to be kept constantly within reach of the patient, so 
that he may frequently rinse his mouth with it, and afterwards 
swallow a portion. From one to two pints are sufficient for the 
twenty -four hours ; and about half of this quantity, containing one 
or two drachms of the chlorate, should be swallowed. 

It cannot be doubted that the amelioration in the symptoms 
which almost always takes place under the use of the chlorate, is 
due to the remedy and not to the mere suspension of the mercurial, 
since the stomatitis will often relapse if the salt be too soon dis- 
continued. The therapeutic action of the chlorate is also proved 
beyond question by Eicord's experiments, which show that the sto- 
matitis will subside under its use if the mercurial be continued, and, 
in many cases, even if the dose be increased ; and that the chlorate 
may be employed as a prophylactic from the commencement of 
treatment in persons who are peculiarly susceptible to the morbid 
action of mercury, without interfering with the remedial effect upon 
the syphilitic symptoms. 1 This statement has been confirmed by 
Laborde. 2 

During the use of mercury, much may be done to prevent sali- 
vation by attention to cleanliness of the mouth, and by avoiding 
exposure to sudden changes of temperature and to moisture; and 
these precautions should be continued for some little time after the 

1 Ricord, Lecons sur le Chancre, p. 336. 

2 Laborde, Gaz. des Hop., Apr. 24, 1858. 

33 



514 TREATMENT OF SYPHILIS. 

suspension of treatment. The teeth should be brushed several 
times a day, or the mouth be rinsed with some astringent gargle, 
as diluted tincture of myrrh, or equal parts of brandy and water 
with the addition of alum. The influence of cold and wet must 
not be regarded as chimerical. I have known a country physician 
to be profusely salivated a month after the cessation of a mercurial 
course, as a consequence of exposure to the rain while attending to 
his practice. But the apprehension which is often entertained by 
patients in regard to the use of cold drinks, provided other hygienic 
conditions be favorable, is probably groundless. 

Other morbid effects of mercury, as the eruption upon the skin 
(eczema mercuriale) which sometimes follows mercurial inunction ; 
mercurial trembling, and other affections of the nervous system ; 
mercurial spana3mia and cachexia, etc., are so infrequent at the 
present day, that I shall refer the reader for their minute descrip- 
tion to the standard works upon Materia Medica, and especially to 
the admirable treatise of Prof. Stille. 1 It would hardly seem 
possible that any physician who has been educated in the modern 
views of the treatment of syphilis could carry the use of mercurials 
to such an extent as to produce the more severe morbid effects of 
this mineral. 

Mercury has undoubtedly been charged with many evil results 
of which it is entirely innocent, and it is much to be regretted that 
such errors have been promulgated and strengthened in the minds 
of a timid public by some members of our own profession. Let it 
be observed that I do not deny the powerful agency of this mineral 
for evil as well as for good, nor that it is often used unnecessarily 
and injudiciously, to the detriment of the general health and 
aggravation of the disease which it is intended to cure ; but to 
ascribe to its employment many of the later manifestations of 
syphilis, as iritis, orchitis, and tertiary lesions in general, which are 
known to occur in cases where no mercurial has been given, and 
which are never met with when this mineral is administered for 
other diseases than syphilis, nor among those who constantly work 
in mercury, is an unfounded and dangerous doctrine, and one which 
returns upon the profession and impedes its action on occasions 
when this mineral is one of the greatest boons from nature to 
man. 

( Therapeutics and Materia Medica, by Alfred Stille, M. D., Phil. 1860. 



SALIVATION. 515 

The public mind is so prone to receive any marvellous account 
of the disastrous effects of drugs, and so many charlatans find it 
for their interest to foster such delusions, that the utmost caution 
is required to avoid being carried along with the tide beyond the 
bounds of careful observation and of truth. As an instance in 
point, we may cite the supposed identity of affections of the bones 
from mercurial dyscrasia and from syphilis, which chiefly rests upon 
a report by Hermann 1 of the diseases prevailing among the workers 
in mercury in the mines of Idria, and this account has assumed 
such importance as to justify my quoting an able criticism upon it 
by the well-known German physiologist, Yirchow, in which its 
inconclusive character is fully shown. 

Yirchow says: "Hermann has published some investigations 
upon diseases occurring at Idria, based upon personal observation 
and information furnished by Dr. Groerbez, from which he concludes 
that a series of affections which are commonly regarded as belonging 
to constitutional syphilis, are due to mercurial intoxication. I must 
confess that after reading his paper it is difficult for me to agree 
with him. In the year 1856, 122 of 516 workmen had diseases 
which were regarded as the effect of mercury. Among them there 
is not a single case of iritis, orchitis, or tubercles of the skin, and 
only two cases of caries occurring in patients who were not em- 
ployed at the furnace where there is the greatest exposure. Her- 
mann himself saw thirty patients, including two with caries, one 
with softening of the spinal column, one with periostitis and necrosis, 
and five with pains in the bones. In the two cases of caries, the 
disease affected the joints, which scarcely ever occurs in syphilitic 
caries. And, after all, what do these cases prove ? Is it at all sur- 
prising that out of 500 workmen two should be found suffering with 
caries? Why are we to conclude that the periostitis with necrosis 
was mercurial and not traumatic, rheumatic, or strumous? There is 
nothing to show that the pains in the bones, resembling those syphi- 
litic pains which precede deep lesions of the osseous tissues, really 
had a specific character. Everybody knows that there is a mercurial 
cachexia, neuralgia, rheumatic pains (mercurial arthritis), affections 
of the mouth and pharynx, mercurial tremor, etc., but to infer that 
these lesions are identical with those of constitutional syphilis would 

1 Wien. Wochenschrift, Nos. 40-43, noticed in the Times and Gazette, June 11, 
1859, p. 616. 



516 



TREATMENT OF SYPHILIS. 



require much care in the choice of arguments and very careful ob- 
servation. Eeder very truly says that any one who has ever seen 
secondary symptoms can refute Hermann's observations and conclu- 
sions." 1 Virchow adds that he has not been able to find any proof 
of the frequent assertion that men working in mercurial mines are 
subject to diseases of the bones identical with those produced by 
syphilis, and that, on the contrary, information derived from his 
colleagues is entirely opposed to this belief. M. Mitscherlich ascer- 
tained at Idria that the workmen were not subject to caries and gum- 
my tumors, and this statement is confirmed by the Official report of 
two physicians at Almaden. Singer 2 ascertained that those work- 
men who are exposed to the fumes of mercury, as gilders and 
hatters, are not affected with such diseases, and Pappenheim, 3 who 
describes the affections of men employed in the preparation of 
rabbit-skins, does not mention a single lesion resembling constitu- 
tional syphilis. In short, any direct action of mercury upon the 
bones is at best very questionable. 

For myself, I can say that I have never seen any effect of 
mercury which could, for a moment, be mistaken by an experi- 
enced person for any form of syphilis ; and the only affections of 
the osseous tissues, which I have observed to follow the use of this 
remedy, have been caries of the teeth and alveoli, in a few persons 
who had frequently been salivated ; but such lesions are evidently 
merely secondary to changes in the soft parts. Some authors who 
admit that mercury is alone incapable of producing any symptoms 
resembling syphilis, still believe that it may in some way combine 
with the syphilitic virus, and give rise to a mongrel disease which 
has been called " hydrargyro-syphilitic." I suspect that the only 
foundation for this idea, which is certainly contrary to all analogy, 
is the fact that mercury when administered injudiciously, depresses 
the system, and aggravates the existing disease; and the simple 
enunciation of this important truth is more likely to attract the 
attention it deserves, than when the fact is concealed beneath a 
very questionable hypothesis. There are two golden rules for the 
administration of mercury, and he who follows them will have no 
occasion to fear doing his patient harm: — 

1 Virchow, La Syphilis Constitntionnelle, traduit de l'Allemand, par le Dr. Pi- 
card, Paris, 1860. 

2 Wochenblatt der Zeitsch. der Wiener Aerzte, 1857, No. 12, p. 197. 

3 Handb. der Sanitaets Polizei, Berlin, 1858, vol. ii. p. 5. 



DURATION OF TREATMENT. 517 

1. Never give mercury "unless the disease be clearly syphilitic; 
except in a few doubtful cases, in which it may be cautiously em- 
ployed and its effects narrowly watched, until the propriety of con- 
tinuing it can be determined. 

2. Avoid the use of mercury in subjects already depressed; and, 
in all cases, suspend the treatment the moment the general health 
appears to suffer. 

I have often been surprised at the large amount of mercury 
which may be administered with benefit in some obstinate cases of 
syphilis ; and occasionally when the disease has repeatedly relapsed 
and I have felt reluctant still farther to increase the quantity, pa- 
tients who had at first feared the effects of mercury, but who had 
been convinced by experience of its benefits, have insisted upon its 
repetition. 

Duration of Treatment. — It is hardly necessary to remark that 
treatment should be persevered with as long as any syphilitic 
symptoms remain. While these persist, specific remedies must be 
continued in doses graduated according to the effect produced and 
the general condition of the patient, increasing the quantity if fresh 
symptoms appear or old ones cease to improve; diminishing it, or 
suspending treatment altogether for a time, if intestinal irritation, 
salivation, general malaise, or decided cachexia supervene; in all 
cases seeking the aid of hygienic influences, and in many that of 
tonics. In the early stages of the disease, induration of the base 
of the primary sore, and more frequently that of the neighboring 
ganglia, will remain after the more evident symptoms of constitu- 
tional infection have disappeared, and treatment must be continued 
until they also have been dissipated. No permanent relief can be 
anticipated unless the base of the chancre has resumed its normal 
suppleness, or retains only the products of simple inflammation, 
and the ganglia have lost their characteristic hardness, although 
these bodies will, of course, always remain perceptible to the touch, 
and may be somewhat larger than they were originally. 

Yet after all this has been accomplished, and when no trace 
remains to mark the radical change which has been brought about 
in the system, experience shows the necessity of still farther pro- 
longing treatment, if we would hope to secure immunity for the 
future. Unfortunately no definite rules can be laid down to deter- 
mine for how long a time this should be, and it is probable that no 
invariable period can ever be fixed upon, since the tendency of the 



518 TREATMENT OF SYPHILIS. 

disease to relapse varies greatly in different subjects, and all stand- 
ards must be more or less arbitrary. We, accordingly, find that 
while authorities upon syphilis are nearly unanimous in recom- 
mending a continuance of treatment after all symptoms have dis- 
appeared, yet that there is no uniformity in their statements as to 
the time required. 

Some take as a standard the period which has already been 
occupied in subduing the previous symptoms, and would have the 
treatment still continued for half or the whole of the same length of 
time. Others are content with a month or six weeks, irrespective 
of the previous duration of treatment ; while many prudent practi- 
tioners advise a period of from six months to two years. Again, 
there is an equal diversity in the recommendations as to the form 
of mercurial to be employed, the mode of its administration, and 
the extent to which it should be made to affect the system; some 
preferring the bichloride in small doses, and never pushing it to 
the extent of touching the gums; others employing some more 
active preparation at repeated intervals, and pushing it on each 
occasion until the mouth is slightly affected ; and others still keep- 
ing their patients upon the verge of salivation during the whole 
period of prophylactic treatment. 

With regard to the short periods of a few weeks, recommended 
by some authors, I do not hesitate to say that, in my opinion, they 
are entirely inadequate to prevent a relapse, although they cannot, 
in many instances, be exceeded, owing to the unwillingness of 
patients to take medicine for a long time after its necessity has 
ceased to be apparent ; and I am convinced that the belief in the 
efficacy of prophylactic treatment, continued for such short periods, 
has been derived from cases in which no secondary symptoms ever 
appeared, and in which chancroids have been mistaken for true 
chancres. I would, therefore, range myself decidedly among those 
who advocate the use of remedies for a period varying in different 
cases from six months to a year, or even longer, after all secondary 
manifestations have disappeared. Especially with patients who are 
already married, or who intend to marry, every precaution should 
be used to prevent a relapse. 

The advantages of the bichloride, under these circumstances, 
are very great, and probably sufficient to entitle it to the prefer- 
ence in most cases. It is less likely to salivate than other forms of 
mercury, has a less depressing effect upon the system, may gener- 



DURATION OF TREATMENT. 519 

ally be continued with impunity for a long period, does not neces- 
sitate such frequent attendance upon the surgeon, and thus relieves 
the patient, in a measure, from the irksomeness of treatment, or 
enables him to absent himself for the purposes of business or of 
pleasure ; — advantages which may render him more willing to con- 
tinue treatment for the necessary time, and which are of no small 
value, provided always they do not lead to imprudence or neglect. 

In administering the bichloride as a prophylactic against future 
symptoms, I have found it desirable to employ as large doses as 
can conveniently be borne — as, for instance, one-eighth of a grain 
two or three times a day — for a period of, at least, six weeks or two 
months, after which time the quantity may be gradually diminished. 
In several cases, in which I have relied upon one-sixteenth or one- 
twentieth of a grain, I have had the mortification of seeing fresh 
symptoms appear, just as I was about to terminate the treatment 
and dismiss the patient as cured. 

During the continuance of prophylactic treatment, the same hy- 
gienic rules should be observed as at an earlier period, and the 
patient should be particularly cautioned not to be led, under the 
mistaken idea that his recovery is now secure, into any imprudence 
which will be likely to favor a relapse. If the system be depressed 
from any cause, this should, if possible, be removed. If the strength 
fail, it should be supported by tonics ; the treatment must be tem- 
porarily suspended, if salivation, intestinal irritation, or nervous de- 
pression ensue ; in short, the general condition of the patient should 
be maintained as nearly as possible at the normal standard of health. 
After continuing the bichloride for six months or a year — when 
this can be done without injury to the constitution, and when the 
patient can be induced to submit — it is important to resort to the 
iodide of potassium, either alone, or alternated with the iodide of 
iron, for an additional period of several months. 

The use of the bichloride, as above recommended, is the treatment 
best adapted to the majority of cases, but other forms of mercury 
are sometimes to be preferred. Thus, I have met with instances 
in which the bichloride appeared to be entirely inadequate to pre- 
vent a relapse, and in which it was necessary to resort to one of 
the iodides, or to mercurial fumigation. The reader will also un- 
derstand that I have been speaking of the secondary and not of the 
tertiary stage of syphilis. In the latter, some modification of the 
above measures, to be described presently, is required. 



520 TKEATMENT OF SYPHILIS. 

Eicord's method of treating secondary syphilis is deserving of 
description, on account of the extensive field of observation and the 
just celebrity of this eminent surgeon. So long as any symptoms 
of constitutional syphilis remain, Kicord relies upon them as a 
guide to determine the quantity of mercury which should be given ; 
being satisfied with any amount which produces an amelioration, 
and increasing it whenever no improvement is manifest. After the 
disappearance of all syphilitic manifestations, he continues mercu- 
rials in the largest dose which can be borne without producing 
salivation, in order to be sure that the system is fully under its 
influence. This is done by increasing the dose until irritation of 
the gums is produced, and then slightly decreasing it so as to avoid 
salivation; afterwards continuing the same quantity for several 
weeks, and again trying the effect of an increase. By a succession 
of such experiments on the power of the system to support the 
mercurial, and by giving as large doses as can be borne without 
salivation, the full effect of the remedy is constantly maintained. 
With regard to the total duration of treatment, Eicord says : " It 
remains to determine for what length of time treatment should be 
continued in order to insure the greatest probability of no farther 
symptoms occurring. No treatment continued for any length of 
time will afford certain immunity ; all we can do is to render im- 
munity probable. To stop treatment as soon as all syphilitic symp- 
toms have disappeared, is to leave our patient with almost a cer- 
tainty of their return. To continue treatment for as long a time 
after as has been required to effect their disappearance, is also an 
unsatisfactory rule. In many cases it would be too short, in others 
too long. Clinical observation of a large number of cases can alone 
furnish a reliable guide. Six months of treatment by mercury, in 
such doses as to exert a curative action on the symptoms as long as 
they remain, and after their disappearance to show by its physio- 
logical effects that it is still acting on the system ; and afterwards, 
three months of treatment with iodide of potassium, in order to 
prevent late manifestations of the diathesis ; such is the mode and 
length of treatment which I have found most successful, and which, 
in the great majority of cases, neutralizes, as it were, the syphilitic 
poison. It is to be understood, however, that this rule is frequently 
to be modified to suit the circumstances of individual cases." 1 

1 Author's edition of Ricokd and Hunter on Venereal, 2d ed., p. 498. 



DURATION OF TREATMENT. 521 

The only peculiarity of the above method is the extent to which 
mercurials are carried in the prophylactic treatment pursued after 
the disappearance of all syphilitic manifestations. When secondary 
symptoms subside, as they frequently do, in a few weeks after com- 
mencing treatment, and in all cases of infecting chancre unattended 
as yet with general manifestations, Eicord would keep the patient 
upon the verge of salivation for a period of nearly or quite six 
months. I must confess that if I were the patient, I should hesitate 
whether to prefer a cure on these conditions or the disease itself; 
and I am convinced from several trials of this plan that but few 
persons can support it, if at all, without injury. In the only case 
in which I have felt justified in carrying it out to its full extent, 
the result did not tend to inspire confidence in its efficacy. The 
patient, an intelligent merchant, had conscientiously pursued six 
months' treatment with mercury (the protiodide) in as full doses as 
could be borne without producing salivation, and three months' 
with iodide of potassium, when about six weeks after completing 
the latter, he was suddenly attacked with epileptiform convulsions, 
of which he had six within twenty-four hours, and which were pre- 
ceded by no symptoms except a constant headache for several weeks 
previous. He recovered sufficiently in a few days to resume his 
business, but a month after had a recurrence of the convulsions 
which left him in a state of nervous excitement bordering upon 
mania. I could not believe that his symptoms were due to his con- 
stitutional disease for which he had so recently and so thoroughly 
been treated, but I came to the contrary conclusion a fortnight later 
when a specific eruption made its appearance, and when I immedi- 
ately put him upon the use of the bichloride combined with tonics, 
under which he rapidly improved and has since been free from 
similar attacks. Except in this one case, I have always been 
obliged to slacken the severity of Eicord's method, in consequence 
of the general health of patients appearing to suffer, and yet, as I 
have before remarked, it is not well to rely upon too small doses 
of mercury and run the risk of seeing relapses appear in the midst 
of treatment. The happy mean has seemed to me to be to give 
mercurials as freely as can be done consistently with the general 
health; and slight tenderness of the gums on several occasions 
during the course of treatment should be regarded as desirable. 

Mr. Thomas Hunt, of London, has recommended another mode 
of conducting the treatment of syphilis which I have employed in 



522 TREATMENT OF SYPHILIS. 

some instances with very satisfactory results, and which is deserv- 
ing of mention, since in a disease so obstinate as this sometimes 
proves to be, the resources of the surgeon cannot be too numerous. 
Mr. Hunt's method 1 is founded upon the idea that mercury exerts 
its therapeutic action suddenly and within a limited period only, 
beyond which its effect is null or injurious. He, therefore, advises 
that it should be administered in short and vigorous courses, giving 
such doses as will most speedily affect the system until its action 
becomes manifest, then entirely withholding it for a time, and sub- 
sequently resuming it in the same manner, as often as may be neces- 
sary. Mr. Hunt prefers blue pill to other preparations of mercury 
on account of its greater activity. In the first course, he administers 
from two to seven grains morning and night until some improve- 
ment in the disease is manifest, and does not persist for a single day 
beyond this, but substitutes aperients and tonics for the mercurial. 
In two or three weeks he commences the second course, giving 
mercury in increased and, in most cases, doubled doses, to provide 
against the tolerance which is acquired by use. Thus he goes on 
with repeated and energetic courses, always aiming to produce an 
impression upon the disease as rapidly as possible, and stopping as 
soon as this effect is attained, and when all symptoms have disap- 
peared he administers a final course as a preventive and pursues it 
until fetor is perceptible in the breath or the patient complains of a 
metallic taste in the mouth. In the later courses he often combines 
inunction with frequent internal doses, with or without opium, in 
order to obtain more speedy mercurial action. Mr. Hunt's method 
is especially adapted to weak and cachectic subjects in whom I have 
repeatedly employed it with success, although the occurrence of 
relapses in some cases has shown that the author's anticipations as 
to the immunity afforded by the final preventive course, are some- 
what too sanguine. 

In concluding these remarks upon the mercurial treatment of 
syphilis, it would be interesting to ascertain what results are 
generally obtained in practice, and to know in what proportion of 
cases, after treatment has been faithfully pursued, no further trou- 
ble is experienced. Unfortunately there are no reliable data 
which enable us to decide this point. Our views of the nature of 

1 On Syphilitic Eruptions, etc., with especial reference to the Use and Abuse of 
Mercury, by Thomas Hunt, F. R. C. S., 2d ed., London, 1854. 



DURATION OF TREATMENT. 523 

syphilis, as a constitutional disease in which the system undergoes 
a modification similar to that which takes place in vaccination and 
variola, render it improbable that any treatment, however pro- 
longed or however faithfully pursued, will afford certain immunity 
for the future. The extreme rarity with which syphilis is con- 
tracted twice by the same person shows that as a general rule the 
diathesis, when once acquired, exists for life ; and we can no more 
hope to eradicate it by mercury than we could expect that medicine 
would restore the system to its original condition after vaccination ; 
and while the diathesis exists, however long it may have been 
latent, there can be no certainty that it will not at some future time 
resume its activity. 

These deductions from the nature of the disease are confirmed 
by experience. Those who have enjoyed the greatest facilities for 
observing the effect of treatment are nearly unanimous in the 
opinion that absolute security can never be attained, and I would 
caution the student against placing the slightest confidence in the 
contrary statements of a few authors who have some favorite mode 
of practice to recommend. 

My own experience leads me to believe that most cases of in- 
fecting chancre are sooner or later followed by secondary manifes- 
tations in spite of any treatment which may be adopted. I have 
met with some unquestionable cases in which remedies have been 
faithfully employed for six months or a year, and in which no 
general symptoms have ever appeared, but they have been so 
infrequent as to be almost exceptional. The majority of patients 
whom I have been able to watch for two or three years have not 
escaped further trouble, though often of a slight character, and 
observation of cases which have been under the care of other 
surgeons and many of which have been subjected to treatment that 
has been pronounced infallible, has convinced me that my own 
experience is that of the profession generally, although it is seldom 
acknowledged, and is not apparent to those who confound the 
two species of chancre and treat both alike with mercury. I would 
not go so far as Diday, who somewhere says that " mercury pre- 
vents those secondary symptoms alone which would never have 
appeared without it," but I believe that most cases of infecting 
chancre are followed by some general symptom in spite of any 
treatment which it is practicable to adopt. 

When secondary symptoms have already appeared I have found 



524 TKEATMENT OF SYPHILIS. 

the results of treatment more satisfactory, and in many cases after 
a thorough course of mercurials no subsequent trouble has been 
experienced; and, as was stated at the commencement of this 
chapter, even when repeated relapses have taken place, persever- 
ance in the use of remedies has been crowned with ultimate 
success, with but few exceptions ; the tendency of the disease to 
reappear has finally ceased, and the patient has been left in a con- 
dition of apparent health which has been maintained until the 
present time. 

At the close of treatment the patient should always be cautioned 
to lead a regular course of life and avoid all depressing influences, 
especially for the first year or two, during which the disease ex- 
hibits its maximum tendency to relapse and is very likely to reap- 
pear if the general health be much reduced ; though, indeed, the 
fact that a man has once had constitutional syphilis should ever 
afterwards lead him to take good care of himself. 

Iodine and its Compounds. — The therapeutic effect of iodine 
and its compounds upon syphilitic symptoms is in direct ratio to 
the duration of the disease. Although possessing little if any 
power over early secondary manifestations, their action upon 
tertiary lesions and those of the transition stage is very decided. 
In deep tubercles of the cellular tissue, rupia, syphilitic orchitis, 
affections of the bones and periosteum, syphilitic cachexia, etc., 
the results of their employment are frequently almost magical. 
An unfortunate patient whose life has been rendered miserable for 
months by pains in his bones which have deprived him of sleep, 
by a pustular eruption upon his face which has debarred him from 
society, by deep ulcerations about the pharynx which have ren- 
dered speech and deglutition almost impossible and which finally 
threaten suffocation, or who has suffered from any other of the 
numerous late manifestations of syphilis, will in most cases obtain 
comparative ease and comfort in the course of a few days or weeks 
from the administration of the iodides. It would be difficult to 
name the circumstances under which the surgeon feels more pride 
in his profession, or in which he finds more conclusive evidence of 
his power over disease, than when he is able to recognize the 
symptoms which indicate the exhibition of these remedies and can 
watch their marvellous effects from day to day. Unfortunately 
the iodides possess greater power to subdue tertiary symptoms for 



IODINE AND ITS COMPOUNDS. 525 

a time than to cause their permanent removal. The disease 
rapidly declines and disappears nnder their use, but in most cases 
returns in a few weeks or months after their suspension ; and thus 
the patient becomes the slave of medicine, or is obliged to resort 
to mercury for an effectual cure. 

But these preparations are none the less of very great value. 
Mercury, when given at the commencement of the treatment of 
tertiary syphilis, cannot, as a general rule, be supported, and rarely 
fails to aggravate the symptoms. By the use of the iodides the 
patient finds almost immediate, though temporary relief from suf- 
fering, his appetite improves, he gains flesh and strength, and his 
system is brought into a proper condition for the administration of 
remedies which will prove of more lasting benefit. 

The ground above taken with regard to the therapeutic value of 
iodine and its compounds is at variance with that assumed by some 
most eminent authorities and especially by Eicord, who considers 
the iodide of potassium as much a specific for tertiary as mercury 
is for secondary symptoms. In my own practice, however, I have 
rarely been able to secure permanent relief for my patients unless 
the former agent was accompanied or followed by the latter, and 
this experience coincides with that of Sir Benj. Brodie, Langston 
Parker, and Mr. Hunt, of Eng., and Drs. Mussey, "Willard Parker, 
John Watson, TVm. H. Yan Bur en, Blackman, 1 and other eminent 
surgeons of this country. Persons are frequently met with who 
have taken the hydriodate of potassa for years and years, and who 
are still obliged to continue it if they would keep their symptoms 
in check. They generally become familiar with its use, purchase 
and mix it for themselves, and take it as regularly as their daily 
meals. An old man is now in attendance upon the New York 
Eye Infirmary, whose face is deeply scarred and nose sunken from 
the effects of syphilis. I am informed by Dr. Greo. Wilkes, for- 
merly surgeon of this Institution, that this man was a patient there 
ten years ago, when he was in the habit of buying the iodide of 
potassium for himself by the pound and taking the enormous 
quantity of an ounce a day ; and I find on inquiry that he has 
continued its use from that time, although he has gradually reduced 
the amount, and now takes but about half a drachm per diem. 

The observations of MM. Melsens and Gruillot have proved that 

1 See Blackman's Vidal on Venereal Diseases, 1st ed., p. 320. 



526 TREATMENT OF SYPHILIS. 

iodide of potassium is capable of rendering soluble mercury or any 
of its compounds retained within the tissues of the body and of 
causing their elimination through the urinary secretion, in which 
they may be detected by chemical analysis. In this manner, mer- 
cury which has been retained in the system is again rendered solu- 
ble, and before elimination may exercise any of its therapeutic or 
morbid effects. Thus iodide of potassium administered subse- 
quently to a mercurial course has frequently been known to excite 
profuse salivation. 

The question has been raised whether iodide of potassium by 
itself has any power over syphilis, and whether its therapeutic 
action may not be entirely explained by the facts above stated. 
According to this view it is only curative because it has the power 
of rendering active mercurial preparations which have been accu- 
mulated in the system by previous treatment; while others who 
believe that tertiary syphilis is an effect of mercury have ascribed 
the action of iodide of potassium to the elimination of this mineral 
and the consequent removal of the supposed cause of the disease. 
Neither of these suppositions will bear the test of examination. 
Cases of tertiary syphilis in which mercury has not previously been 
given, and in which, therefore, the independent action of iodide of 
potassium may be tested, are not common ; but a sufficient number 
have been met with to prove that this agent does not play so secon- 
dary and insignificant a part as has been attributed to it. Of 195 
cases of syphilis successfully treated with iodide of potassium by 
Hassing, of Copenhagen, in 70 no mercurial treatment whatever 
had been employed. 1 

A woman recently entered Nelaton's wards with numerous exos- 
toses upon the tibias, the femoral bones, the bones of the forearms 
and the thoracic fibro-cartilages, which were attended with such 
severe pain as totally to deprive her of sleep. She stated that she 
had had this disease for three years and had never received any 
treatment whatever. The iodide of potassium was administered in 
the dose of fifteen grains a day, and by the third day she was able 
to pass a quiet night, and at the end of a week the osseous tumors 
had lost their sensibility and resolution had commenced. 2 This 
case can leave no doubt that the administration of the iodide of 
potassium may effectually control tertiary syphilis when mercury 

1 British and Foreign Medical Rev., Oct. 1845, p. 482. 

2 Gaz. des Hopitaux, Jan. 28, 1860. 



IODINE AND ITS COMPOUNDS. 527 

has not been previously given. This conclusion, however, does 
not conflict with the belief that its therapeutic action may some- 
times be due in part to the liberation of mercury. 

The solubility of iodide of potassium enables it to be adminis- 
tered in any aqueous or alcoholic mixture, while its deliquescent 
properties poorly adapt it for the pi hilar form. Five grains three 
times a day is the usual dose with which to commence treatment in 
an adult, and if the case be properly selected, marked improvement 
will generally take place within a week. In old cases of syphilis, 
however, this quantity is often insufficient, and it may be necessary 
to increase the dose to a drachm, and, in exceptional cases, to two 
drachms or more per diem. When the symptoms appear to indi- 
cate the use of the hydriodate, the case should not be pronounced 
intractable to this remedy unless a trial has been made of full doses 
and these have been found to be without effect. Eicord, who was 
one of the first to follow Wallace, of Dublin, in the use of this 
agent, and whose experience with it has probably been greater than 
that of any other surgeon, administers from fifteen grains to a 
drachm and a half per diem, and rarely exceeds the last named 
quantity. His colleague at the Hopital du Midi, M. Puche, fre- 
quently employs an ounce and a half (50 grammes) in the twenty- 
four hours, and states that he has rarely observed any bad effects ; 
this practice, however, is not deserving of imitation. 

The following are convenient formulae : — 

$. Potassii iodidi §ss. 

Aquae cinnanioini gss. 
M. 

Seven drops of this solution contain nearly five grains of the 
iodide. 

R Potassii iodidi gij. 

Aquae giij. 
M. 
A teaspoonful three times a day. 

The action of the iodide of potassium is increased by combination 
with muriate of ammonia, which is a favorite addition with my 
venerable friend, Dr. John P. Batchelder, of this city, 

R. Potassii iodidi, 

Ammonia? muriatis, aa 5j. 

Tinct. cinchona? comp. ^iv. 
M. 
A tablespoonful three times a day. 






528 TREATMENT OF SYPHILIS. 

Experience shows that the most favorable time for the adminis- 
tration of the iodide of potassium is half an hour or an hour after 
eating, although Dr. Budd remarks that it should be taken fasting, 
"lest it be decomposed by the hydrochloric acid of the gastric 
juice." It not unfrequently excites griping pains in the bowels, 
which may be avoided by the addition of a syrup containing tannic 
acid, as the syrup of cinchona or of orange-peel. 1 The addition of 
a small quantity of tannic acid to solutions of the iodide in a syrup 
which does not contain tannin answers the same purpose. The fol- 
lowing formula is employed by Kicord and Nelaton : — 2 

R,. Potassii iodidi gj. 

Syrupi corticis aurantii ^vj. 
M. 
Dose. — A tablespoonful. 

Dr. Durkee states that he is in the habit of combining the iodide 
of potassium with carbonate of ammonia, which he thinks renders 
this substance more agreeable and efficient. He employs the fol- 
lowing formula : — 3 

R. Ammonise carbonatis 5i ss « 

Potassii iodidi ^iij. 

Syrupi sarzse comp., 

Aquae, aa giiss. 
M. 
Dose. — One drachm three or four times a day. 

The iodide of sodium 4 and the iodide of ammonium 5 have been 
recommended as substitutes for the iodide of potassium by Dr. 
G-amberini, of the Hospital of Saint Orsola, Bologna. 

The iodide of iron cannot be said to possess any special anti- 
syphilitic power, but is an extremely valuable tonic in cachectic or 
chlorotic subjects either with or without the iodide of potassium. 
I am in the habit of employing it in nearly all cases of constitu- 
tional syphilis, especially towards the close of treatment and after 
the use of mercury. Blancard's pills are the most convenient form 
of administration, or the liquor ferri iodidi may be employed. As 
the iodide of iron is frequently given to women who pride them- 

1 Boinet, Traite d'lodotherapie, Paris, 1855, p. 102, and L'Union Med., 1858, p. 
487 ; also same journal for March 6, 1860. 

2 Richelot, L'Union Med., Feb. 28, 1860. 

3 Gonorrhoea and Syphilis, p. 325. 

4 Dublin Quarterly Journ., No. 28, Nov. 1852. 

5 Gaz. des Hop., Dec. 1, 1859. 



IODINE AND ITS COMPOUNDS. 529 

selves upon their complexion, it is well to know that it sometimes 
gives rise to papular, tubercular, and furuncular eruptions, like other 
compounds of iodine. This fact is denied by Mr. Langston Parker, 1 
but I have met with a number of unquestionable instances in my 
own practice from the use of Blancard's pills, though I cannot 
recall any when the syrup has been employed. 

The contra-indications to the use of iodide of potassium are acute 
or chronic inflammation of the digestive organs, plethora, and a 
disposition to hemorrhages. A few persons are entirely insensible 
to its influence, and it is useless to persist in its employment if a 
fair trial, commencing with moderate doses and gradually increas- 
ing to large ones, prove unsuccessful. 

In cases adapted to its use, the effect of the iodide of potassium, 
if given in sufficient quantity, is usually perceptible in the course 
of a week. The appetite increases, the digestive powers improve, 
and the patient rapidly gains in flesh and strength. Grassi's anal- 
yses of the blood show that this remedy possesses a much greater 
power than mercury to increase the proportion of blood-corpus- 
cles, and hence is especially adapted to the treatment of syphilitic 
cachexia. 

Iodide of potassium rarely occasions such unpleasant effects as 
to demand more than a mere temporary suspension of its employ- 
ment. Its morbid action is chiefly manifest upon the various mu- 
cous membranes. Some patients, shortly after commencing its use, 
are seized with coryza, which is sometimes quite severe, and accom- 
panied with acute pain in the frontal sinuses ; others are attacked 
with oedema of the conjunctiva oculi and swelling of the lids ; irri- 
tation about the fauces and bronchitis are occasionally met with, 
and even oedema of the glottis. Gastro-intestinal irritation is a 
frequent symptom which has already been adverted to. Loss of 
vision, apparently dependent upon sub-retinal effusion, has been 
observed in a few rare instances. Salivation sometimes occurs, but 
is never as severe as that occasioned by mercury, nor is it ever 
attended by ulceration like the latter. It has been asserted that 
iodide of potassium produces atrophy of the breasts and of the 
testicles ; but this is denied by Eicord, who states that he has accu- 
rately measured the scrotal organs before and after treatment, and 
has never found any diminution in their volume, unless they were 

1 Modern Treatment of Syphilitic Diseases, Am. ed., Phil. 1854, p. 258. 

34: 



530 TREATMENT OF SYPHILIS. 

affected with, syphilitic orchitis, which generally terminates in atro- 
phy. Iodide of potassium may hasten this result, when it would 
inevitably have taken place without it, but cannot produce it in 
healthy organs. Langston Parker also coincides with Kicord in 
the opinion that the prolonged use of the iodide does not produce 
wasting of the testes and mammas. 

One of the most frequent morbid effects of this remedy consists 
of various eruptions upon the integument, generally in the form 
of papules or pustules resembling acne, and often of furuncles or 
boils. They are quite common about the neck and face, where 
they present an unsightly appearance and are the source of much 
annoyance to patients who frequent society; and also upon the 
trunk and upper extremities. The eruptions produced by the ad- 
ministration of iodide of potassium and other compounds of iodine 
have been carefully studied by Dr. H. E. Fischer, 1 of Vienna, who 
divides them into the erythematous, papular, tuberculo-pustular, 
and eczematous. 

In the erythematous form, the skin, and especially that covering 
the forearm, assumes an intense red color, which is sometimes iso- 
lated in points, and at other times covers the whole surface ; the 
temperature of the part is also heightened. This erythema disap- 
pears if the treatment be suspended, or, if the latter be continued, 
runs into the following form. 

The papular, which is by far the most common form, may ap- 
pear over the whole integument, but is chiefly met with, upon the 
extremities and abdomen. The papules are but slightly elevated 
above the surface ; are of an intense red color, which disappears on 
pressure ; measure from half a line to two lines in diameter, and 
resemble urticaria; the larger papules are surrounded by a red 
areola, and are sometimes isolated and at other times in groups. 
They are developed without any general febrile disturbance, have 
no injurious effect upon the general system, and disappear without 
desquamation upon the suspension of the iodide. 

The tuberculo-pustular form is rarer than either of the preceding, 
and is chiefly met with in strumous subjects. A red spot, attended 
with itching, is first observed, which is soon transformed into a 
small tubercle, with or without an areola ; in most cases a vesicle or 
pustule forms on its summit, which sometimes bursts and discharges 

1 L'Union Medicale, Jan. 31, 1860; from the Wien Medizin. Wochenschrift. 



IODINE AND ITS COMPOUNDS. 531 

its contents, and at other times dries into a scab, which falls off, 
leaving only the tubercle behind it. The tubercles are of a bluish 
color, throw off scales in the process of resolution, and are very 
slow to disappear, even if the iodide be suspended. They leave 
behind them stains of a bluish-red color, which are often indelible. 
Intermediate forms, consisting of vesicles, pustules or boils, have 
been noticed by several writers. 

The eczematous variety, which closely resembles ordinary eczema, 
is very rare. It most frequently affects the hairy scalp and the 
neighborhood of the scrotum, and soon disappears on stopping the 
iodide. M. Mercier 1 describes a case in which moderate doses of 
iodide of potassium, upon two occasions in the same person, brought 
out an eruption of eczema rubrum over the whole body, attended 
by severe fever and dyspnoea, and so copious an exudation of fluid 
that the bed on which the patient lay was completely wet through. 
In all the cases upon which these observations were made, the 
preparation of iodine employed was either the iodide of potassium 
or of sodium. The eruptions did not appear to depend upon the 
quantity administered, since they were often produced by small 
doses, and were frequently absent when the remedy was pushed to 
iodism. 

Mr. Langston Parker has described a hard, tubercular condition 
of the tongue, which is sometimes cracked and fissured, consequent 
upon the long-continued use of iodine. 2 This affection closely 
resembles syphilitic tubercles, from which it may be distinguished 
by its disappearance soon after the discontinuance of the iodine. 

In addition to the morbid effects already mentioned, iodide of 
potassium in large doses sometimes gives rise to a combination of 
symptoms known under the name of " iodism," and consisting of a 
sensation of oppression in the head, tinnitus aurium, neuralgia, 
spasmodic action of the muscles, impaired voluntary motion, and 
sluggishness of the intellect. Eilliet has also described a form of 
iodic intoxication which he calls " constitutional iodism," charac- 
terized by rapid emaciation, an enormous appetite, and nervous 
palpitation, and which is, moreover, peculiar in this respect that it 
is produced by minute rather than by large doses of the iodide of 

1 Observations Nouvelles sur le Traitement des Valvules du Col de la Vessie, 
Paris, 1847, and L'Union Medicale. Feb. 11, 1860. 

1 Provincial Medical and Surgical Journal, No. 3, 1852 ; also, Syphilitic Diseases, 
p. 211. 



532 TEEATMENT OF SYPHILIS. 

potassium and other compounds of iodine. Eilliet's observations 
were all based upon cases in which iodine was employed in the 
treatment of goitre in Switzerland. His paper was the subject of a 
lengthy discussion before the French Academy of Medicine in 
1860, in which Eicord, Velpeau, Gibert, Trousseau, and Bou- 
chardat took a prominent part, and in which no very definite con- 
clusion was arrived at. It was generally confessed, however, that 
Eilliet's observations, coming from so accurate an observer, were 
worthy of confidence, but that the affection described was unknown 
to the members of the Academy, many of whom had had very ex- 
tensive experience in the use of iodine and its compounds ; and it 
was suggested that the goitre, for which the remedy was given, 
might have had some influence in the production of the above 
mentioned symptoms. 

Vegetable Decoctions and Infusions. — Decoctions and in- 
fusions of sarsaparilla, saponaria, water-dock, stillingia, and other 
vegetable substances have at times enjoyed considerable reputation 
with the profession for the cure of syphilis, and are still held in high 
repute by the public. When used alone they are found to be en- 
tirely destitute of anti-syphilitic properties, and when given in 
combination with mercurials and iodide of potassium, do not appear 
to add to the effect of the latter. This statement coincides with the 
opinion of most surgeons 1 who have had the largest experience in 
their use, and has recently been confirmed, so far as regards sarsa- 
parilla, the reputation of which has exceeded that of all the others, 
by a series of careful experiments conducted by Sigmund, of Vienna, 
who concludes that this substance does not exercise the slightest 
perceptible influence on the course or termination of syphilitic dis- 
eases. 2 Whatever virtues are possessed by these substances can 
only be ascribed to their influence as tonics, stomachics, diuretics, 
or diaphoretics, to which the ordinary mode of their administration 
in a large amount of fluid greatly contributes. When employed 
with these purposes in view they may prove useful adjuvants of 
mercury and iodide of potassium, but alone are unworthy of con- 
fidence. 

The ordinary decoctions and infusions are very bulky, and their 

1 See Stilus's Materia Medica, ii. p. 948. 

2 British and For. Med.-Chir. Rev., Am. ed., July, 1860, p. 183. 



NITRIC ACID — SYPHILIZATION. 533 

preparation not always convenient ; I am therefore in the habit of 
using Thayer's fluid extracts, which I have found very reliable. A 
teaspoonful of the compound fluid extract of sarsaparilla, prepared 
by this chemist, may be mixed with a tumblerful of warm water at 
the time of using. 

Zittman's decoction (Yid. U. S. Dispensatory), which enjoys a 
high reputation in Germany, is of two kinds, the stronger and the 
weaker. " Of the former, the patient is required to drink eighteen 
ounces every morning before rising, and of the latter, thirty-six 
ounces every afternoon, and of the stronger decoction, again, eighteen 
ounces every evening, during four or five days." These prepara- 
tions contain an appreciable amount of mercury, and their adminis- 
tration is associated with a rigid diet, aperients, and rest in bed. 

Nitric Acid. — Nitric acid was formerly recommended by Alyon, 
and others, for the treatment of syphilis, and is still a favorite 
remedy with the homoeopaths. I have employed it as a tonic with 
satisfactory results in the late stages of syphilis when mercury was 
inadmissible, but the iodide of potassium is, in most cases, more 
reliable. 

SYPHILIZATION. 

About the year 1844, M. Auzias-Turenne, of Paris, undertook a 
series of experiments to test the accuracy of the doctrine advanced 
by Hunter and Ricord, that syphilis was not communicable to 
the lower animals, and after protecting the inoculated points in 
such a manner that the animal could not lick the sore and thus 
remove the virus, succeeded in developing soft chancres upon 
monkeys, cats, rabbits, and horses ; and that the ulcers thus pro- 
duced were truly chancroids was fully proved by four successful 
inoculations of their secretion upon the person of M. Robert de 
Welz, of Wurzburg, who offered himself for the purpose. These 
results were afterwards confirmed in three experiments performed 
by Diday, of Lyons, in one of which he inoculated the secretion of a 
chancroid upon the ear of a cat, thence transferred the virus to the 
opposite ear of the same animal, and finally inoculated matter from 
the second sore upon his own penis. The result was a phagedenic 
chancre and bubo, which remained open for four months before 
cicatrization took place, and seriously affected his general health, 



534 TKEATMENT OF SYPHILIS. 

although neither then nor since have any constitutional symptoms 
appeared. 

These experiments conclusively prove that the virus of a soft 
chancre may be inoculated upon the lower animals and from them 
back again to man. The same has been maintained of the virus 
of true syphilis, several instances having been reported in which 
secondary and tertiary lesions are said to have occurred in animals 
after artificial inoculation, but in none of which is the fact estab- 
lished beyond a doubt, and this point must therefore be left open 
for future observation. 

On November 18, 1850, M. Auzias announced to the French 
Academy of Sciences that while performing these experiments he 
had observed that the first chancre inoculated upon an animal 
was more rapidly developed, was of a larger size, secreted a greater 
quantity of matter, was surrounded by more intense inflammation, 
and was more persistent than the second ; that the second bore the 
same relation to the third ; the third to the fourth, and so on, and 
that finally a period arrived when further inoculations entirely 
failed. The condition of the animal after immunity was attained 
was compared by the author to the protection afforded by vaccina- 
tion against variola, and the process was denominated syphilization. 

I find that similar phenomena had been observed before the 
time of M. Auzias ; since Dr. Graves, 1 in quoting Dr. Fricke, of 
Hamburg, says: "If a person affected with chancre were inocu- 
lated with the matter of that chancre on a fresh spot, and from 
this on a third and so on, it will be found that this process can be 
repeated only a few times with success. The individual becomes, 
as it were, habituated to the virus, and less capable of its influence." 
These remarks, however, of Fricke, had attracted but little attention, 
or had been forgotten when Auzias announced his discovery in 1850. 

The facts now stated are the basis of the modern doctrine and 
practice of syphilization. Although their discoverer had not at 
this time subjected them fully to the test of experiment upon man, 
yet he did not hesitate to draw from them certain general conclu- 
sions which may be summed up as follows : — • 

1. The system may be so saturated with the syphilitic 2 poison 

1 London Medical Gazette, 1838-9, vol. i. p. 697. 

2 This was before the distinct nature of the two species of chancre was recog- 
nized, and Auzias, like many subsequent observers, erroneously supposed that his 
experiments were performed with the true syphilitic virus. 



SYPHILIZATION. 535 

b y successive inoculations, that the farther application of the virus 
will prove innocuous. 

2. Syphilization may be resorted to as a prophylactic against 
syphilis in healthy persons, in the same manner as vaccination is 
employed as a preventive of variola. 

3. Syphilization is capable of curing persons already infected 
with syphilis. 

The proposition to employ syphilization as a prophylactic agent 
in healthy persons did more than anything else to prevent the 
new doctrine from receiving the attention it deserved, and was 
the chief cause of the violent opposition it received and of its final 
rejection before the Academy. This idea was never, I believe, 
entertained by any one except its author, who himself soon aban- 
doned it. 

It would serve no useful purpose to enter into a minute account 
of the history of syphilization from that time to the present. Suf- 
fice it to say that it was for the first time put in practice upon a 
large scale, in January, 1851, by Sperino, Physician and Surgeon 
in Chief to the Syphilocome or Venereal Hospital at Turin, who, 
in May of the same year, made a report to the Medico -Chirurgical 
Society of that city, in which he gave the histories of fifty -two 
prostitutes who had been cured of syphilis by the new method ; 
and in 1853 he published a large work upon syphilization in 
which the whole subject was thoroughly discussed, and the number 
of cures reported was increased to ninety-six. Meanwhile Gram- 
berini at Bologna and Gulligo at Florence pursued similar investi- 
gations with results which were equally favorable to the new 
doctrine. 

The practice of syphilization for the cure of syphilis thus origi- 
nating among the ardent temperaments of the South of Europe 
was destined to be still further investigated by the cooler heads of 
a more northern clime, where it has since been pursued with a 
degree of candor, impartiality and scientific research which absolve 
it from the charge of being the wild scheme of crack-brained en- 
thusiasts, and which entitle it to profound consideration. Dr. "Wil- 
liam Boeck, Professor of Medicine in the University of Christiana, 
while travelling in Italy in 1851, heard of Sperino's experiments, 
and upon his return home determined to repeat them upon patients 
under his charge. He was not able, however, to obtain inoculable 
virus until October, 1852, when his first inoculations were made, 



536 TREATMENT OF SYPHILIS. 

and in March, 1858, he had already syphilized more than two hun- 
dred persons. 1 Other Scandinavian physicians soon took up the 
same practice, and hence the results obtained in Norway and Swe- 
den are those which chiefly claim our attention, and which afford 
the most reliable data for arriving at the correct explanation of the 
phenomena first observed by Auzias-Turenne and Sperino. 

The method of performing syphilization is very simple, and 
consists of successive inoculations of chancrous matter upon some 
convenient part of the body, either the lower part of the abdomen 
or the arms and thighs being generally selected. Sperino prefers 
the former and Boeck the latter regions. The virus on each occa- 
sion subsequent to the first is taken from the sores produced by 
the preceding inoculations, of which Boeck makes from eight to 
ten every three days. More frequent or more numerous punctures 
are not considered desirable, since it is stated that when the process 
of syphilization is carried on with great rapidity, immunity is at- 
tained before the syphilitic symptoms are cured. 

Boeck never resorts to syphilization for primary syphilis alone, 
regarding it as uncertain whether general symptoms will follow, 
and limits the practice to the secondary and tertiary forms of the 
disease. He states that it is only the first twenty or thirty chancres 
which attain any considerable size ; that the subsequent ones become 
smaller and smaller; and that finally inoculation of the matter 
which was first employed ceases to have any effect whatever when 
implanted beneath the epidermis. When immunity to the first 
virus is obtained, he takes fresh matter from another source, with 
which he is able to produce a new series of inoculations, but the 
sores are never so large nor can as many be made as in the pre- 
ceding series. A third or even a fourth or fifth fresh quantity of 
matter may succeed in exciting a few insignificant pustules, but 
finally complete and permanent immunity is obtained, when chan- 
crous matter from any source whatever has no more effect than so 
much water. "We shall see hereafter, that this statement of Dr. 
Boeck is denied by Dr. Faye and others. Boeck states that in a 
few instances he has been able to effect a permanent cure of syphi- 
lis with matter from one source alone. 

Boeck resolutely pursues the treatment in spite of any alarming 

' Communication to the Medico-Chirurgical Soc. of Edinb., March. 3, 1858, Edinb. 
Med. and Surg. Journal, April, 1858. 



SYPHILIZATION. 537 

symptoms which may siipervene. He regards the occurrence of 
phagedena as an indication for persevering in the inoculations, and 
even looks upon intercurrent iritis without apprehension, and says 
that it disappears spontaneously and without any special treatment. 
In respect to the results of this practice, Boeck divides patients 
into two classes, those who have been exempt from all previous 
treatment, and those who have already taken mercury. He has 
found that the former without a single exception can be cured by 
syphilization alone. The latter do not improve with the same uni- 
formity; relapses frequently occur, and it is often necessary to 
administer preparations of iodine in conjunction with the treatment 
by syphilization. 

Boeck resorts to syphilization in the syphilis of infants as well 
as of adults. The effect upon the general health is decidedly bene- 
ficial. Patients are allowed to eat and drink what they please, 
and to continue their usual avocations. Weak subjects never fail 
to gain in flesh and strength, and after being fully syphilized are 
as strong and healthy as they were before they were attacked with 
syphilis. 

At the time when his communication to the Medico- Chirurgical 
Society of Edinburgh was written, Boeck had met with only three 
relapses in one hundred cases, and these were cured by a second 
syphilization, in which but a small number of inoculations was 
requisite. The average duration of treatment in ordinary cases 
was about six months, and in the more severe cases of inveterate 
syphilis from seven to eight months. In summing up the results 
of his practice, Boeck says : u I have, indeed, the most sincere con- 
viction and proof — 

" 1. That there is no fact more certain, in medical and surgical 
therapeutics, than the fact of the curability of constitutional syphilis 
by syphilization. 

" 2. That this method of curing constitutional syphilis is infinitely 
more certain than the methods of cure by mercury, iodine, hunger- 
cure, or any other means yet proposed. 

"3. That it is free from the dangers attending the mercurial 
treatment; and 

" 4. That relapses are more rare after this than after any other 
known method of treating secondary or tertiary syphilis." 1 

1 Letter to the Medical Times and Gazette, Sept. 19, 1857, p. 305. 



538 TREATMENT OF SYPHILIS. 

Boeck lias wavered somewhat in his opinion as to the necessity 
of continuing the treatment after the syphilitic symptoms have dis- 
appeared and until absolute immunity to the virus is attained, but 
his last as well as his first statements are in favor of this course. 

Dr. Eaye, of Christiana, who has taken *a prominent part in the 
discussions relative to syphilization, although he has had no per- 
sonal experience in the practice, does not deny its power to cure 
syphilis, but maintains that the supposed immunity is fictitious, 
and that if the chancrous virus be' applied in larger quantities and 
more deeply beneath the skin, the inoculations will almost inva- 
riably succeed. He relates two instances in which he was thus 
able to produce chancres in persons who had passed through a 
course of syphilization, and who were thought to be insusceptible 
of farther inoculation. 

Numerous other physicians of Norway and Sweden have restated 
to the practice of syphilization, of whom the most eminent is Dr. 
Danielssen, of Bergen, who has employed inoculations of chancrous 
virus both for the purpose of curing syphilis, and with the hope 
(which does not appear as yet to have been realized) of so modifying 
the constitution of persons affected with lepra, though free from 
syphilitic taint, as to destroy the leprous diathesis. Dr. Danielssen 
believes that the so-called immunity to the chancrous virus, which 
has been supposed to be attained by saturation of the system with 
the poison of syphilis, is simply a loss of reacting power in the 
skin which it sooner or later regains ; and in accordance with this 
view, which I believe to be correct, the immunity is not permanent, 
but merely temporary. 

Sufficient has now been said with reference to the manner of per- 
forming syphilization, and its origin and progress up to the present 
time. It remains for us to inquire what credit can be given to the 
results reported by the advocates of this new mode of practice, and 
how the phenomena which are said to have been observed are to 
be explained. 

1. Is syphilization an efficient and safe method of treating constitu- 
tional syphilis f — With the testimony before us, there can be but 
one answer to this question, and that in the affirmative. The inocu- 
lations of Boeck, Danielssen, and others, have been performed, not 
in private practice and under the observation of a few persons only, 
but in public hospitals, where they could be seen by any one who 
chose to witness them. The novelty of the practice has naturally 



SYPHILIZATION. 539 

attracted numerous visitors, not only from the neighborhood, but 
also from a distance, and, from among them all, not a single voice 
has been heard to call in question the truth of the cures reported ; 
on the contrary, the testimony in favor of their authenticity is 
universal. At an animated discussion relative to the theory of 
syphilization before the Norwegian Medical Society, which was con- 
tinued for six meetings, it was generally admitted that the facts in the 
case could not be impugned, and several members who had formerly 
been violently opposed to the new practice, but who had been led 
to examine it more carefully, publicly gave in their adhesion to it. 

Among the visitors from abroad who, from personal examina- 
tion, have reported in favor of syphilization, and whose position 
adds weight to their testimony, are the editor of the Dublin Quar- 
terly Journal of Medicine, and the author of an able article in the 
Medico- Chirurgical Review. The former says: "During a visit paid 
by the editor of this journal to Stockholm, last autumn (1856), he 
saw under the care of his friend, Professor Malmsten, in the Sera- 
phim Hospital, some cases of secondary syphilis which had been 
cured, and some which were progressing towards cure, by the 
syphilization treatment, after having obstinately resisted all other 
therapeutic means. He was much interested in this subject, the 
more especially as he had previously altogether discredited the 
statements which had been published as to its efficacy as a thera- 
peutic agent, but could no longer doubt the living evidence which 
was there submitted to his observation, and the testimony of several 
of the most celebrated physicians and surgeons of the Swedish 
capital." 1 

The latter says: "It seems, indeed, a bold assertion to maintain 
that one of the most intense animal poisons can be annihilated, as 
it were, by the introduction of fresh poison into the system, until 
at length the venereal virus has no more effect on the patient than 
a drop of water. That such immunity does take place, we must 
concede as an undoubted fact. The unanimous testimony of Boeck, 
of Danielssen, of Sperino, and of Auzias-Turenne, of Carlsson, and 
of Stenberg, in Stockholm, all concur on this point; nor could we 
anywhere obtain a denial of this fact, either from the patients or 
from Dr. Boeck's colleagues, when we visited Christiana this past 
summer." 

1 Dublin Quarterly Journal of Medical Science, Feb. 1857, p. 77. 



54:0 TREATMENT OF SYPHILIS. 

With reference to the improvement of the general health during 
the process of syphilization, this reviewer says: "Singular as this 
may seem, it is most certainly true, as we have ascertained from 
personal observation in the Christiana and Bergen hospitals. We 
conversed with several of the patients, and questioned them upon 
this point, and all declared that their general health had greatly 
improved under the treatment. Full diet was allowed, and it may 
be suggested that this contributed much to the improvement ob- 
served, as it is, perhaps, of a more nourishing character than the 
ordinary diet of the Norwegian laborer. The sensations of weari- 
ness, the sleeplessness, and the pains resembling rheumatism, rapidly 
disappeared, and the aspect of many of the patients presented an 
appearance of health such as could not have been expected. More- 
over, the patients, when cured, could at once return to their ordi- 
nary occupations — they could expose themselves to the vicissitudes 
of the climate, to wet and to cold, without the fear of evil conse- 
quences, such as might justly be apprehended in those who had 
undergone a mercurial course." 1 

A distinguished writer on venereal, M. Melchior Kobert, of Mar- 
seilles, has published five cases of successful treatment of syphilis 
by means of syphilization, and has declared himself a convert to 
the new doctrine. 2 Prof. Hebra — if we may believe a paragraph 
in recent medical journals — has taken the same ground; and, 
finally, Diday, 3 in a review of Melchior Eobert's paper, admits that 
syphilitic symptoms disappear under repeated inoculations of the 
chancroidal virus, but only, as he maintains, in consequence of 
depuratory action, and not from absorption of the poison. 

With such an amount of evidence before us, we must either 
altogether deny the value of testimony or admit the safety and 
efficiency of syphilization in the treatment of syphilis. 

2. Mow are the facts of syphilization to he explained? — Auzias- 
Turenne and Sperino both believed that the therapeutic effect of 

1 British and Foreign Med.-Chir. Rev., April, 1857, p. 319 and 324. I desire to 
acknowledge my indebtedness for much that is contained in the present section 
to this review, and especially to another by the same author in the number of this 
journal for January, 1S59. In the latter, the able writer abandons the theory that 
the system becomes saturated from absorption of the virus, and adopts the opinion 
of Dr. Danielsseu, that the disappearance of the symptoms is due to prolonged sup- 
puration. 

2 Pamphlet in 8vo., pp. 45, Marseilles, 1859. 

3 Gaz. Med. de Lyon, No. 19, 1860. 



SYPHILIZATION. 541 

syphilization was due to the absorption of the virus and the satu- 
ration of the system with the poison; but as Dr. Faye remarks, 
"no system of physiology or pathology has as yet made us ac- 
quainted with a chronic zymosis or blood-poisoning, which, under 
a constant reintroduction of the poison, operates in one case bene- 
ficially and in another is followed by the most serious consequences ;" 
and this theory of syphilization, advanced by its founders, was so 
contrary to all rules of pathology that it was a great obstacle to 
the speedy reception of the new doctrine. Boeck was unwilling 
to adopt this theory, to which he objected that if saturation really 
took place the symptoms would become worse instead of better. 
He did not, however, attempt to offer a substitute, and confessed 
that he adopted the practice on empirical grounds alone. It should 
be observed that neither of these three authors admits a distinction 
between the virus of the soft and that of the hard chancre. 

The first approach to the true explanation of the facts observed 
in syphilization was made by Prof. Faye, who, as before stated, 
denied the prophylactic power of this method, and asserted that the 
alleged immunity to the virus was only "a temporary immunity of 
the over-stimulated skin, and that the cure of the syphilitic symp- 
toms was due to the depuratory action of the sores excited by 
successive inoculations." This theory, which was much more in 
accordance with our general ideas of pathology than the one ad- 
vanced by Auzias and Sperm o, was yet deficient in that it was not 
sustained by any known facts, and it consequently failed to attract 
the attention it deserved. The proof which was wanting has since 
been supplied by Danielssen, whose experience with syphilization 
in lepers not affected with syphilis has conclusively shown that no 
absorption of the virus takes place, and consequently that the cure 
of syphilitic symptoms cannot be due to saturation of the system 
with the poison. He gives the histories of six cases in which ino- 
culations were performed upon persons untainted with syphilis 
with the virus commonly used in syphilization, but in which the 
treatment was not pushed to the extent of so-called immunity, and 
in not one of the six did any general symptom appear. 

With reference to these cases, Danielssen remarks : " It appears 
from the above details, that neither one chancre, nor two, nor three, 
nor six, nor thirty-six, nor one hundred and thirty-six have in the 
preceding cases induced secondary syphilis, and that, therefore, the 
direct operation of the inoculations has been exclusively limited to 



542 TREATMENT OF SYPHILIS. 

the spot where the chancres had shown themselves. If such be the 
case, we are justified in assuming that no greater number of chan- 
cres will produce a different result. And this is confirmed by our 
experience ; for with one exception, to which we shall subsequently 
allude, not one of those individuals, previously free from all syphi- 
litic taint, whom I have syphilized, have been affected by secondary 
syphilis; nor have they shown any signs of the existence of the 
venereal diathesis in their systems. Nor, in those already affected 
with syphilis, have I observed under syphilization the slightest 
evidence of their having imbibed the poison afresh. So far from 
seeing in syphilization a new physiological fact, as Boeck denomi- 
nates it, I have, on the contrary, found it confirm a long-established 
axiom, viz., that the simple soft chancre does not affect the system, 
and consequently does not produce constitutional syphilis. Among 
the many thousand artificial chancres that I have seen, I have not 
observed one (with a single exception) which was not of this char- 
acter, both in my own practice and in that of my colleagues, and 
as inoculated on every part of the body. Even on the face, the soft 
chancre followed inoculation, contrary to Eicord's experience, who 
had always observed the indurated chancre there." 1 

The exceptional case referred to in the above remarks is highly, 
important, since it strongly confirms the position here assumed. 
Syphilization had been performed upon a leper with the virus of 
the soft chancre to the extent of nearly 400 inoculations, when the 
secretion of an indurated chancre was accidentally inoculated. The 
inoculated point healed, but a month afterwards an indurated sore 
appeared followed by unmistakable signs of secondary syphilis, show- 
ing that the previous inoculations with the chancroidal virus, which 
had been strictly local in their action, had afforded no protection 
whatever against true syphilis. 

Danielssen's conclusions as to the kind of virus which has been 
employed in reported cases of syphilization. are borne out by an 
examination of the writings of Boeck and others. Boeck, for in- 
stance, states that the best matter for the purposes of syphilization 
is that derived from a chancre attended by a suppurating bubo ; 
but a primary sore with this accompaniment is generally a chan- 
croid and not a true chancre. Again, all observers state that a 
pustule is so far developed by the second or third day after inocu- 

1 Medico-Chirurg. Rev., Jan. 1859, p. 98. 



SYPHILIZATION. 543 

lation, as to furnish matter for fresh inoculations ; but the absence 
of a period of incubation and a pustular form at the outset are 
characteristics of the soft and not of the hard chancre. The value 
of this testimony from Boeck is increased, because given uncon- 
sciously by one who does not recognize the distinction between the 
two kinds of primary sore. Yet, after all, there is no necessity to 
search for these minor indications to enable us to determine what 
species of virus has been employed in successful inoculations of 
persons already infected with syphilis, since the experiments of 
Eicord, Fournier, Kollet, and many others, have conclusively shown 
that under these circumstances those only can succeed which are 
performed with the secretion of the chancroid. 

As already stated, Danielssen attributes the disappearance of the 
syphilitic symptoms during the process of syphilization to depura- 
tory action, and in confirmation of this opinion, calls attention to 
the fact that in tertiary syphilis, nature herself often produces deep 
suppurations under which, if the strength holds out, all secondary 
symptoms disappear. 

Admitting the plausibility and in all probability the correctness 
of this explanation, we cannot, therefore, infer that the same effect 
would be obtained from issues or setons; since the soft chancre, 
when once implanted beneath the epidermis, spontaneously main- 
tains its hold upon the integument for weeks or even months, and 
is with difficulty eradicated ; while a sore produced by the knife or 
caustic constantly tends to heal, and can only be kept open by irri- 
tants or the introduction of some foreign substance ; and since the 
conditions of the existence of these two lesions are so widely differ- 
ent, it is not unreasonable to suppose that the effect will not be the 
same. Farther observation and experiment are, however, requisite 
to fully settle this point. 

The only attempt in this direction, so far as I am aware, has 
been made by Cullerier, 1 who has experimented with a rapid suc- 
cession of numerous blisters in the treatment of syphilis, and states 
that they gradually lose their effect upon the integument and 
finally excite but little if any irritation. The effect of this treat- 
ment upon the syphilitic manifestations does not appear to have 

1 Pakisot, Traitement de la Syphilis par les Vesicatoires Multiples. These de 
Paris ; reviewed in the Arch. Gen. de Med., July, 1858, p. 93. 



544: TREATMENT OF SYPHILIS. 

been very satisfactory, although several cures are said to have been 
obtained. 

Oar present knowledge of the results and theory of syphilization 
may be summed up in the following propositions : — 

1. The evidence appears to be indubitable that the treatment of 
syphilis by syphilization in efficiency and safety is equal and proba- 
bly superior to the treatment of the same disease by mercury. 

2. The susceptibility of the skin to the development of chancroids 
diminishes under repeated inoculations ; until finally apparent im- 
munity is attained. 

3. The secretion of simple chancres has alone been employed in 
the successful inoculations of syphilization upon persons tainted 
with syphilis. 

4. No absorption of the virus takes place, and the therapeutic 
effect is probably due to the depuratory action of prolonged sup- 
puration. 

5. The immunity which is acquired is probably neither absolute 
nor permanent, and consists in a partial and temporary loss of 
reacting power of the skin consequent upon over-stimulation. 1 

6. The facts of syphilization do not conflict with, but, on the 
contrary, sustain the doctrine of the duality of the chancrous 
virus. 

While the study of science should never be pursued at the ex- 
pense of morality or modesty, no false ideas of morality or modesty 
should deter scientific men from the investigation of truths which 
are likely to benefit mankind. The only immorality . and im- 
modesty in syphilization as originally proposed, was the wild 
scheme of its founders to subject to this process those persons who 
were free from syphilitic taint. Of how little value such a course 
would be is evident from Donalssen's case referred to above. The 
idea itself was soon abandoned by the men who originated it, and 
has not at the present day a single advocate. Divested of this folly 
and sustained as it now is by the testimony of high minded and 
honorable men, syphilization is a subject of pure scientific interest 
which no one need fear to discuss nor carefully to experiment upon, 

' Every practitioner must, I think, have noticed the fact that, in employing 
liniments containing croton oil, aqua ammonia, etc., it is necessary from time to 
time to increase the proportion of the irritant, or otherwise the application ceases 
to affect the skin. 



SYPHILIZATION. 545 

with the laudable object in view of obtaining a more certain cure 
of syphilis, the treatment of which by mercury and iodine is con- 
fessedly imperfect. At the same time it must be conceded that the 
method by which syphilization is accomplished is repugnant to 
the feelings, and it is safe to predict that this mode of practice will 
not be generally adopted, at least in this country, until the already 
strong evidence in its favor shall be followed by proof that is per- 
fectly irresistible. 



35 



546 SYPHILITIC FEVEK. 



CHAPTER VI. 

SYPHILITIC FEVER; STATE OF THE BLOOD; EN- 
GORGEMENT OF THE LYMPHATIC GANGLIA. 

In" many cases of constitutional infection, the appearance of the 
earliest secondary eruption is preceded by certain symptoms which 
resemble those that usher in the exanthemata. The patient suffers 
from a general feeling of uneasiness, is listless and disinclined to 
attend to his ordinary occupations, has a pale, sallow, and haggard 
look, and is attacked with severe headache and rheumatic pains in 
various parts of the body, which are worse at night and deprive 
him of rest. 

The only statistics that I know of from which the frequency of 
this eruptive fever may be accurately determined, are those given 
by Bassereau, who met with it in 143 of 199 cases of syphilitic 
erythema ; and its apparent absence in at least a portion of the re- 
maining cases is attributed, by this author, either to the fact that it 
was overlooked, or to the administration of mercurials for the pri- 
mary sore. 1 Victor de Meric 2 is inclined to doubt the constancy of 
this precursory febrile disturbance, but I have met with it in the 
majority of cases of early secondary symptoms in persons who had 
not taken mercury. 

Although this fever usually precedes by eight or ten days an 
early secondary eruption, it is impossible to regard it as a mere 
forerunner of the latter, since it frequently continues after the 
eruption appears, and in some cases commences at the same time 
or even follows it. 

The headache, which is a prominent symptom, is generally, 
though not always, most severe at night, and appears to be seated 
in the periosteum. It is sometimes diffused over the whole cra- 
nium, and at other times confined to the frontal region. Not 

• Bassereau, op. cit., p. 163. 2 Lettsomian Lectures, p. 29. 



STATE OF THE BLOOD. 54.7 

unfrequently the patient has periodical attacks, consisting of a 
chill, followed by a hot stage and sweating, which recur with great 
regularity at a certain hour of the day, generally towards evening, 
and are liable to be mistaken for intermittent fever. Indeed, 
several cases, in which this error has been committed, are reported 
by Bassereau and Yvaren. 1 

The osteocopic pains of this early stage of general syphilis differ 
from those which belong to the tertiary period in affecting chiefly 
the neighborhood of the joints and in their transitory character. 
They are most severe at night when the patient is warm in bed, 
generally subside towards morning, and are absent during the day 
unless brought on by motion. The larger joints of the upper and 
lower extremities are most frequently attacked, and in some cases 
motion is rendered difficult and painful. Bassereau relates a case 
occurring in Ricord's wards, in which the elbow-joint was swollen, 
red, and incapable of extension, and which a young surgeon had 
mistaken for a dislocation and attempted to reduce. In most cases, 
however, there are no symptoms of local inflammation, except 
perhaps slight tenderness on pressure, and the pain passes from 
joint to joint, or is felt in other parts of the body, as the back of the 
neck, the lumbar region, upon the sternum, etc., and occasionally 
the continuity of the bones is involved. 

In some cases the digestive functions are disordered ; the appetite 
is diminished, the tongue coated, and the patient is attacked with 
nausea and diarrhoea. In others, these symptoms are absent and 
the appetite may even be inordinately increased. Epistaxis, 
oedema of the lower extremities, palpitations, and a bruit de souffle 
accompanying the first sound of the heart and audible both in the 
cardiac region and over the carotids, have also been noted. 

According to Bassereau, these symptoms generally become more 
severe and persist for some time after the appearance of the erup- 
tion, though in some instances they suddenly cease upon the out- 
break of syphilitic erythema or papulae, or diminish and gradually 
disappear in the course of one or two weeks. 

State of the Blood. — The general malaise, lassitude, headache, 
pallor of the countenance, palpitations, and bruit de souffle, belonging 
to this category of early general symptoms, are indicative of chloro- 

1 Metamorphoses de la Syphilis, p. 173 et seq. 



548 SYPHILITIC FEVER. 

anasmia, and that this condition of the system really exists at this 
period of constitutional infection, is still further proved by a series 
of analyses of the blood performed by M. Grassi under the direction 
of Ricord; from which it appears that in persons bearing infecting 
chancres, there is a diminution of the blood-corpuscles and an in- 
crease in the proportion of albumen ; the amount of fibrin is not 
affected. This chloro-anaemia is confined to the early stage of consti- 
tutional infection ; the blood soon recovers its normal composition 
and retains it throughout the whole course of the disease unless 
syphilitic cachexia supervenes. Though foreign to our present 
subject, it may be mentioned incidentally, that the blood of persons 
affected with simple chancres was shown in a second series of 
analyses by Ricord and Grassi to remain unchanged; and thus 
these experiments, which were performed before the question of the 
duality of the chancrous virus had been mooted, are confirmatory 
of the distinction which is now recognized between the chancroid 
and the infecting chancre. 1 

Engorgement of the Cervical Ganglia. — A very important 
symptom of the early stage of constitutional infection, and one which 
the surgeon should never fail to look for in cases of difficult diag- 
nosis, is engorgement of the lymphatic ganglia in various parts of 
the body, and especially those situated upon the lateral and poste- 
rior portions of the neck. We are not here speaking of the indu- 
ration of the ganglia in anatomical connection with primary sores 
— the indurated buboes so-called, which assume their cartilaginous 
hardness about the same time as the base of the chancre. The 
symptom referred to is an engorgement — not induration — of glands 
at a distance from the point where the virus entered the system, 
and first appears some six or eight weeks after the chancre in 
conjunction with other early secondary manifestations. 

This symptom is present in a large majority of cases at this stage 
of the disease. Ricord speaks of it as " perhaps the most constant, 
the earliest, and the most characteristic symptom of constitutional 
syphilis." 2 Bassereau 3 found it in ninety per cent, of all the cases 
of syphilitic erythema which came under his observation ; and in 

• Ricord, Lecons sur la Chancre, 2d ed., p. 184. 

2 Iconographie, Remarks on the case figured in Plate XLV. 

3 Op. cit., p. 68. 



ENGORGEMENT OF THE CERVICAL GANGLIA. 549 

most of the exceptional cases the patients had taken mercury or 
were not seen for some time after the eruption appeared. It is an 
early symptom of constitutional infection, and occurs, if at all, 
within a year after contagion. Eicord states that it is rarely seen 
in persons who contract syphilis after forty years of age, though 
Bassereau met with one case in a man aged sixty-three, and another 
in one aged seventy -four ; from which it would appear that this rule 
is by no means invariable. 

The glands most frequently affected are those situated along. the 
upper two-thirds of the posterior border of the sterno-cleido mas- 
toicleus muscle; but those on the back of the neck beneath the 
occiput, and one just posterior to the ear and over the mastoid pro- 
cess may also be involved. All the glands in the regions mentioned 
are not, however, implicated in the same person; the number is 
frequently but one or two, and rarely exceeds six or eight. In a 
state of health these bodies can with difficulty be detected; but, 
when enlarged by syphilis, they may attain the size of a bean or 
almond, and are often so prominent as to be recognized by the sight 
as well as the touch, and even to attract the notice of the patient's 
unprofessional associates. As a general rule, their number and 
size correspond to the extent and severity of the neighboring erup- 
tion upon the scalp. 

Other glands besides those of the neck may be engorged in the 
same manner. Sigmund has especially insisted upon enlargement 
of a lymphatic gland situated between the biceps and triceps 
muscles just above the internal condyle of the humerus, where I 
have in several instances observed it, although I do not believe it 
to be as constant as Sigmund's remarks would lead one to suppose. 
Bassereau has found the glands of the axilla affected, but only in 
case there was a papular or pustular eruption in the neighborhood 
of the shoulder. The submaxillary ganglia are also not unfre- 
quently tumefied, when the throat is the seat of syphilitic angina 
or when the mouth is made sore by the use of mercury. 

This engorgement of the ganglia almost invariably terminates in 
resolution. In one case only, so far as I am aware, has suppura- 
tion been known to take place. This occurred in a patient, aged 
30, of a scrofulous habit, under the care of Bassereau, in whom 
two collections of matter were formed in the cellular tissue around 
the gland, attended by severe febrile excitement and requiring 
puncture. 



550 SYPHILITIC FEVER. 

Some difference of opinion has been entertained as to the ques- 
tion whether this engorgement is necessarily dependent upon a 
neighboring eruption upon the scalp or integument. Eicord be- 
lieves that it is not, and states in support of his opinion that it 
often occurs before the slightest trace of an eruption is visible ; 
and to meet the objection that a pustule of ecthyma might be 
concealed in the hair and escape notice, this surgeon has repeatedly 
shaved the head and proved the scalp to be intact. Admitting, 
however, that the engorgement of the glands precedes the eruption, 
it does not disprove the connection between the two, which is 
rendered probable by the correspondence in their intensity ; and 
swelling of the submaxillary glands, as is well known, is often 
anterior to an eruption of erysipelas upon the face. 



SYPHILITIC AFFECTIONS OF THE SKIN. 551 



CHAPTER VII. 

SYPHILITIC AFFECTIONS OF THE SKIN. 

Syphilitic are distinguished from other eruptions by certain 
peculiarities, no one of which by itself possesses absolute value, but 
several of which combined are generally sufficient to establish the 
diagnosis. 

The color of a syphilitic eruption will often indicate its origin. 
No very definite idea of this color, however, can be conveyed by 
words. To be appreciated, the eye must be educated to detect it 
upon the living body, and the student should neglect no oppor- 
tunity to compare this and other objective symptoms of specific 
eruptions with those pertaining to their congeners of different 
origin. The older writers on venereal compared it to the cut sur- 
face of a ham; 1 it is now commonly known as the copper color; 
but both these comparisons fail to convey a perfect idea of the 
exact hue that is intended. It is best described as a reddish- 
brown with a slight admixture of yellow, which in many cases is 
modified by the natural color of the skin and by the age of the 
eruption. 

The copper color of syphilitic eruptions, however, is by no means 
constant, and may be simulated by various forms of skin disease 
which are not dependent upon the syphilitic virus. Thus it is 
never seen in mucous patches, which are either red or of a grayish 
white hue. It is absent in most cases of syphilitic erythema at the 
commencement of the eruption, and only appears as the blotches 
begin to fade away; and, as a general rule, in nearly all syphilitic 
eruptions, the copper color is less marked at an early than at a 
late period. Again, the cicatrices of lupus, acne, and variola, 
may assume a reddish-brown color which is readily mistaken for 

1 "Secate per trans versum pernam, talis est color pustularum sine cortice." 
Gabriel Fallopius. 



552 SYPHILITIC AFFECTIONS OF THE SKIN. 

the copper color of syphilis. In spite of these various sources of 
error, which with care may generally be avoided, the peculiarity 
referred to is one of the most valuable means of distinguishing 
syphilitic eruptions from those of simple origin. 

A circular form, although frequent, is less constant in syphilitic 
eruptions than the assertions of some authors would lead us to be- 
lieve. It is often absent in the erythematous and papular eruptions 
of the early stage of syphilis, and is chiefly confined to the pustular 
and tubercular forms which appear at a later period. It is also as- 
sumed by lepra, herpes, and other eruptions of non-specific origin. 

Cazenave has especially insisted upon the thinness of the scales, 
and upon the thickness, greenish color, and tendency to split, of the 
scabs ; and Biett upon the narrow whitish fringe which often sur- 
rounds each patch of a syphilitic eruption, and which is merely 
the remains of the exfoliated epidermis ; but these signs are un- 
reliable. 

Those syphilitic eruptions which are attended by ulceration, as 
impetigo, rupia, ecthyma, and tubercles, are often arranged in cir- 
cular groups; their cicatrices, as a matter of course, assume the 
same form, and are, moreover, of a dirty brown or bronzed color, 
which gradually fades away, and gives place to a dull white. 
Within these circles there is generally a portion of the integument 
which has escaped ulceration, and the presence of isolated depres- 
sions due to distinct pustules or tubercles upon this portion of 
sound skin, or around the outer border of the circle, is highly 
characteristic of the scars of syphilitic origin. Ordinary lupus pro- 
duces cicatrices which are somewhat similar, but the tubercles are 
so closely approximated that the scars run into each other, and are 
also less deep than those just referred to. 1 In general, the cicatrices 
of syphilitic eruptions retain, for some time, the copper color of the 
preceding lesion, but this gradually disappears. 

The syphilodermata are very persistent, but so also are cutaneous 
eruptions of non-specific origin, and in this respect these two classes 
may at first sight appear to be entirely identical ; and yet there is 
a difference, for certain affections belonging to the former, either 
remain for an indefinite period under the same type, or run into 
other forms, while the corresponding affections in the latter are 
transitory and immutable. Thus, ordinary roseola entirely disap- 

1 Basseeeau, op. cit., p. 31. 



SYPHILITIC AFFECTIONS OF THE SKIN. 553 

pears in the course of a few days, while syphilitic roseola, unless 
arrested by treatment, often persists for months, or gives place to 
syphilitic papules or pustules which may continue for years. 

The entire absence, or small amount of pruritus attendant upon 
the syphilodermata is a characteristic and highly important symp- 
tom. It is surprising to observe how little inconvenience is ex- 
perienced by the patient even when the eruption covers a large 
extent of surface; instead of suffering from a constant sensation 
of heat and itching, as is usual in other affections of the skin, he 
will disregard its presence, or even be entirely ignorant of its 
existence. 

Some little caution is requisite, however, in receiving the state- 
ments of patients upon this point. Many persons when questioned 
as to the amount of pruritus, will at first represent it as very con- 
siderable, while an examination of the surface will indicate, by 
the absence of scratches made by the finger nails, that their sen- 
sations are exaggerated, and close inquiry will satisfy the surgeon 
of the correctness of this conclusion. More or less irritation, 
however, often attends syphilitic eruptions in the neighborhood of 
the genital organs and upon the scalp, and may be occasioned in 
other parts of the body by an accompanying eczema of simple 
origin or by scabies. Still the insensibility of the skin referred to 
is, in most cases, a very valuable symptom of the syphilodermata, 
and the presence of severe pruritus should lead the surgeon to 
suspect some other cause than syphilis. On two occasions, when 
called to treat patients supposed to be affected with a syphilitic 
eruption, the attendant itching has induced me to make a careful 
examination of the skin, and has led to the discovery of pediculi 
which were the sole cause of the disease. 

Bassereau has called attention to the frequent coexistence of 
various forms of syphilitic eruptions upon the same person, as an 
important element of diagnosis. In other affections of the skin, we 
rarely, if ever, find a union of blotches, papules, vesicles, and pus- 
tules ; while in the early stage of constitutional infection, owing to 
the rapidity with which one syphilitic eruption runs into another, 
all these different forms are frequently observed at the same time 
upon the same person. This tendency to polymorphism is not 
manifested by the later syphilitic eruptions. 1 

1 A fine specimen of a polymorphous syphilitic eruption, composed of blotches 
vesicles, and pustules, is figured by Rioord, Iconographie, PL X. 



55i SYPHILITIC AFFECTIONS OF THE SKIN. 

The same author has also dwelt upon the entirely distinct char- 
acter of some forms of syphilitic eruptions, and upon the differ- 
ences which exist between others and their congeners among the 
simple affections of the skin. Thus mucous patches are only occa- 
sioned by the syphilitic virus, and certain forms of papules and 
tubercles are exclusively dependent upon the same cause. Again, 
syphilitic vesicles often consist of a papular base, with a slight effu- 
sion of serum at the summit, and syphilitic pustules of impetigo 
rest upon prominent and thickened portions of the integument — 
characters which are never present in the corresponding simple 
affections of the skin. 

The seat of an eruption will sometimes indicate its origin. Thus 
simple acne is confined to the face, trunk, and upper extremities, 
while syphilitic acne frequently involves the thighs and legs. 
Again, ecthyma of the hairy scalp is almost invariably produced 
by the syphilitic poison. 

The coexistence of undoubted syphilitic symptoms will afford 
a strong probability that an eruption is of specific origin; although 
it should not be forgotten that constitutional infection is no bar 
against the outbreak of simple affections of the skin. 

The history of the case must be taken into the account, and the 
symptoms of the preceding chancre and its complications are espe- 
cially worthy of attention as a means of determining whether the 
sore was of the simple or infecting species. The length of time 
since the supposed contagion, taken in connection with the elemen- 
tary lesion of the eruption, is also of value ; thus a roseola cannot 
be due to a chancre contracted eight or ten years, nor tubercles to 
one contracted two months ago. 

i Finally, the influence of treatment may aid in establishing the 
diagnosis, since in cases in which the history of the patient is im- 
perfect and the symptoms obscure, a cautious trial of mercury and 
iodine will often enable us to determine, by the effect produced, 
whether a cutaneous eruption be due to syphilis or to other causes. 
It should not be forgotten, however, that all syphilitic patients do 
not improve under the administration of specific remedies, so that 
the effect of treatment cannot be regarded as infallible. 

I shall follow the classification adopted by Cazenave, and describe 
syphilitic eruptions under the following heads: — 

1. The exanthematous. 

2. The papular. 



SYPHILITIC ERYTHEMA. 555 

3. The squamous. 

4. The vesicular. 

5. The bullous. 

6. The pustular. 

7. The tubercular. 

In describing these eruptions, I shall have frequent occasion to 
refer to the work of M. Bassereau, which is one of the most recent, 
and probably the most thorough, that has appeared on this subject. 
I propose also to indicate in foot-notes the plates of Eicord's ad- 
mirable representations of venereal disease in which the various 
eruptions are figured, in order that they may readily be referred 
to by the student who has access to the work. 

Syphilitic Erythema {Syphilitic Roseola). — Syphilitic erythema 
is the earliest and most frequent of all the syphilodermata. This 
eruption consists of irregular spots of a rose or pale red color which 
disappears on pressure, upon a level with the surrounding surface, 
and either isolated, or variously grouped together, so as to form 
crescents, circles, etc. 1 Sometimes the blotches are of a brighter 
red which is only partially effaced by pressure, are slightly pro- 
minent, and studded with minute elevations, due to distension of 
the cutaneous follicles. This eruption is generally slow and insidi- 
ous in its development, appears by preference upon the abdomen, 
thorax, axillae, and the superior portions of both the upper and 
lower extremities, and is so free from febrile excitement, heat, and 
pruritus, that the patient may not discover its presence unless by 
accident. 

In some cases, however, when hastened by alcoholic stimulants, 
a hot bath, or prolonged exercise, it makes its appearance suddenly, 
is attended by general disturbance of the system, and may cover 
the whole surface of the integument including the face, which, 
under other circumstances, usually escapes. I have known of two 
or three instances in which a hot bath taken a short time before 
going to a party has brought out a syphilitic roseola upon the face 
and neck which was first detected by the man's associates in the 
ball-room. 

The hands are in most cases unaffected, but may also be involved, 
and in a few instances the only traces of the eruption are two or 

1 Iconographie, Pis. XV., XV. bis, ter, et quater. 



556 SYPHILITIC AFFECTIONS OF THE SKIN. 

three blotches upon the palms. Upon the dorsal surface the erup- 
tion assumes the same appearance as upon other parts of the body, 
while upon the palms the blotches are seated upon thickened por- 
tions of the integument, which are slightly prominent and sensitive 
upon pressure, exhibit the copper color to an unusual degree, and 
often become squamous. 1 

Syphilitic roseola gradually assumes a faint copper color, which 
in some cases, however, is absent during the whole course of the 
eruption ; unless arrested by treatment it rarely disappears in less 
than six weeks and may continue for as many months ; as it passes 
off slight exfoliation of the epidermis takes place, and the blotches 
are succeeded by dingy discol orations of the skin, which remain 
for some time. Eelapses often take place within a period of a few 
weeks or months, in consequence of the premature suspension of 
treatment, indulgence in alcoholic stimulants or other depressing 
influences, and are not unfrequently accompanied by a reappear- 
ance of the induration at the site of the chancre. 

I have already quoted in another chapter 2 the statistics of M. 
Bassereau relative to the time of the appearance of syphilitic ery- 
thema, and will at present merely state the general conclusions upon 
this subject arrived at by this able and reliable observer. When 
no mercurial is administered for the primary sore, this eruption 
generally appears between the thirtieth and sixtieth day after con- 
tagion ; it is not uncommon from the sixtieth to the ninetieth day ; 
but is seldom met with as late as the fourth month, and is exceed- 
ingly rare in the fifth ; beyond which time it only occurs in the 
form of a relapse, or in case it has been delayed by mercurials. 
It should be observed that we are here speaking of the earliest 
appearance of the eruption, which having once broken out may 
persist for a long time after the period mentioned. 

Syphilitic roseola should be carefully distinguished from the 
erythematous eruptions which sometimes follow the administration 
of large doses of copaiba and cubebs, and which have frequently 
led to the erroneous supposition that gonorrhoea may occasion 
constitutional infection. The fact that the patient has been taking 
the anti-blennorrhagics should always induce caution in forming a 
diagnosis ; and roseola dependent upon this cause may be recog- 
nized by the febrile excitement and pruritus which generally 

1 Iconographie, PI. XV. ter. z See p. 455. 



SYPHILITIC PAPULES. 557 

attend it, by the absence of other suspicions symptoms, by its 
situation upon parts of the body which are not commonly affected 
in syphilitic erythema, and by its spontaneous disappearance soon 
after the suspension of the anti-blennorrhagic. 

The most frequent concomitants of syphilitic erythema are scabs 
upon the hairy scalp, a crown of copper-colored papulae upon the 
forehead, pustules and papules upon other parts of the body, 
engorgement of the cervical ganglia, rheumatic pains about the 
joints, alopecia, mucous patches within the mouth and in the 
neighborhood of the anus and genital organs, and minute yellow- 
ish scabs surmounting papular elevations at the junction of the 
alas nasi and cheeks, and upon the commissures of the lips (im- 
petigo). 

Syphilitic Papules (Syphilitic Lichen). — Like syphilitic ery- 
thema, syphilitic papules belong to the early stage of constitutional 
infection, but are less common than the former eruption, which in 
many cases precedes them. 

They consist of small solid elevations of the superficial layers of 
the skin, 1 and the neighborhood of the hair follicles appears to be 
most frequently involved, since at an early period of their develop- 
ment, each papule is traversed by a hair which soon falls out. 
They may be scattered irregularly over the surface, arranged in 
annular groups or closely aggregated. Their color is at first roseate 
or a bright red, which disappears on pressure ; but they rapidly 
assume a yellowish red or copper color which cannot be entirely 
effaced. 

Three forms of syphilitic papulae may be recognized : the lenti- 
cular, in which the papules are somewhat broad and flat ; the conical, 
the height of which exceeds their breadth, and which most closely 
resemble ordinary lichen ; and the miliary, which are very small, 
and the summits of which, on their first appearance, are generally 
surmounted by a slight effusion of serum. 

Papules are most common upon the abdomen, thorax, back, fore- 
head, and the upper and lower extremities ; but unless arrested by 
treatment they frequently extend over the whole integument ; they 
are rare, however, upon the hairy scalp, which is generally the seat 
of syphilitic pustules. Their development is in most cases slow and 

1 See Ricord's Iconograplrie, PI. XVII. bis. 



558 SYPHILITIC AFFECTIONS OF THE SKIN. 

by successive invasions, so that papules in their various stages may 
generally be found upon the same person at the same time. In 
some instances, however, they spring up suddenly and may in a 
few days cover the whole body ; and when thus rapidly developed, 
their summits are often covered with a slight effusion of serum, 
which desiccates and forms a scale seated upon a papular base. 

Syphilitic papules are frequently found upon the forehead, ex- 
tending from the roots of the hair to the frontal eminences, where 
they constitute the most frequent variety of the corona veneris so- 
called, which, however, may be made up of other elementary lesions ; 
and it is in this situation especially that the scales which form upon 
the summits of the papules fall off) and leave small, shining and 
copper-colored elevations which are highly characteristic of syphi- 
lis and which betray the disease to an experienced observer. 

Syphilitic papulae are very persistent, and even when subjected 
to appropriate treatment, rarely disappear until after the lapse of 
one or two months. As resolution progresses, the copper color 
fades first into a tawny and then into a grayish hue, and copious 
desquamation of the epidermis sometimes takes place, attended by 
slight pruritus. They very rarely terminate in suppuration and 
ulceration, and yet not unfrequently are succeeded by depressions 
in the skin which are due to interstitial absorption of the tissues, 
and which disappear in the course of a few months. 

In 30 cases of syphilitic papulae observed by Bassereau in which 
no mercury had been administered, the eruption appeared between 
the twentieth and thirtieth day after contagion in 3 ; in the course 
of the second month, in 16 ; and during the third month, in 11 ; 
thus showing that this eruption belongs to a very early period of 
constitutional infection. 

The concomitants of syphilitic papulae are for the most part the 
same as those of syphilitic erythema. Iritis is sometimes observed, 
but less frequently than was supposed by Carmichael, who regarded 
it as the most common attendant upon this form of eruption. 

Syphilitic papules may be confounded with syphilitic tubercles, 
with common lichen, and with acne indurata. Tubercles may be 
distinguished by the later stage of their development, their larger 
size, the greater depth to which they involve the tissues, and by 
their tendency to ulceration. Lichen is attended with considerable 
febrile excitement and severe pruritus, and is rapid in its course 
and termination. It is sometimes extremely difficult to distinguish 



SYPHILITIC SQUAMA. 559 

syphilitic lichen when occupying the nsnal seat of acne, as the 
face, shoulders, or back, from the latter eruption. In such cases 
the presence or absence of other syphilitic symptoms must chiefly 
be relied upon to establish the diagnosis. 

Syphilitic Squama {Syphilitic Pityriasis, Psoriasis and Lepra). — 
Many of the syphilodermata in their later stages are attended by 
desquamation of the epidermis, and may assume the appearance of 
scaly eruptions, when they have had for their initial element ery- 
thema, papulae, or even vesicles and tubercles ; hence some authors 
have been disinclined to admit squamae among the syphilodermata, 
and have referred those cases generally included under this head to 
other eruptions. 

Syphilitic pityriasis, in which the scales are thin and furfura- 
ceous, is chiefly met with upon the scalp, and sometimes upon the 
eyebrows and those portions of the face which are occupied by the 
beard. It may succeed an eruption of erythema or papules, or 
form upon the cicatrices left by vesicles or pustules. Upon the 
head, where it is most common, the epidermic scales are thrown off 
in large quantities, or collect in a continuous scurf about the roots 
of the hair, which generally falls off to a very great extent. 

Syphilitic psoriasis, in which the scales are larger and thicker 
than in the preceding variety, may be developed upon all parts of 
the body. In most instances it succeeds an eruption of papules or 
tubercles, and sometimes of pustules ; while in a few cases it would 
appear to be squamous from the outset. Like common psoriasis, it 
is divided into several varieties dependent upon the form of the 
patches, which in psoriasis guttata are small and scattered ; in pso- 
riasis diffusa, of larger size and more or less continuous ; while in 
lepra they assume the form of circles. The integument beneath 
these patches is the seat of a low form of inflammation, and is of a 
red color, in which the copper hue is often absent. Unlike the 
patches of common psoriasis which are most elevated at the centre, 
those of the syphilitic form of the disease are centrally depressed, 
and are most prominent at the circumference. Slightly depressed 
cicatrices are left after the falling off of the scales, and are due to 
interstitial absorption of the tissues. 

Syphilitic psoriasis of the hands and feet is a very characteristic 
symptom of constitutional syphilis. 1 A red blotch or papule, and 

1 Iconographie, PI XXII. 



560 SYPHILITIC AFFECTIONS OF THE SKIN. 

sometimes a pustule, first appears, generally near the centre of the 
palm of the hand, beneath which the skin is thickened, dry, and 
elevated ; an irregular-shaped patch is formed of variable extent, 
from which the cuticle exfoliates and exposes a red and tender 
surface surrounded by a fringed border consisting of the remains 
of the epidermis. In some cases it commences as a complete ring 
of inflamed and thickened cuticle, including sound integument in 
the centre, and gradually enlarges by peripheral growth; and three 
or four successive rings may spring up within the one first formed. 
These patches are generally raw and tender, and are traversed by 
cracks and fissures, which bleed readily and sometimes give exit to 
a little pus. Complete extension of the fingers may be rendered 
difficult or even impossible. 

In this as in all other affections of the skin, the history of the case 
and the coexistence of undoubted syphilitic symptoms are of the 
utmost value in establishing the diagnosis. Syphilitic psoriasis 
generally appears in weak and anemic subjects, in whose treatment 
tonics should play an important part. 

Syphilitic Vesicles. — A vesicular eruption is the rarest of all 
the syphilodermata, although it is now admitted to be more frequent 
than was at one time supposed. It is one of the earliest syphilitic 
affections of the skin. Of twelve cases observed by Bassereau at 
the Hopital du Midi, none occurred later than the sixth month, and 
the earliest one month after contagion. The parts which are most 
frequently affected are the back, face, and extremities. The vesicles 
may either be large and globular, small and acuminated, scattered 
irregularly over the surface, or arranged in groups. Many of them 
are found to be traversed by a hair, showing that the chief seat of 
the eruption is the hair follicles. Several varieties are admitted, 
most of which find their analogues in the non-specific eruptions of 
the skin. 

In the variety which resembles varicella, the vesicles are large, 
either acuminated or globular, scattered over the surface, in some 
cases umbilicated, and each is surrounded by a copper-colored 
areola. Their contents remain serous for a short time only, and 
soon become purulent. 

In the eczematous variety the vesicles are smaller, and either 
diffused or collected together in groups. They may continue trans- 
parent, or the contained serum may be absorbed, and the eruption 



SYPHILITIC BULL.E — PEMPHIGUS. 561 

terminate in fine desquamation without the formation of scabs, 
this being frequently the case upon the scrotum. Sometimes, as in 
common eczema impetiginodes, a thin ; yellowish crust is formed, 
beneath which the integument is found to be superficially ulcerated. 

The herpetic variety may consist of large, globular vesicles con- 
taining a citrine- colored fluid, and arranged in irregular groups 
seated upon a dark-red base, resembling the patches of herpes 
phlyctenodes ; or the vesicles may be smaller and collected into 
groups which are either circular or ovoid, as in herpes circin- 
natus. 

In a fourth variety described by Bassereau, the bases of the vesi- 
cles are hard and firm papular elevations, which remain for some 
time after the fluid has been absorbed or has escaped by rupture of 
the vesicles. They may even undergo still farther development, 
and assume the appearance of a papular syphilitic eruption. 

These eruptions rarely retain their vesicular form for a long 
period,, but terminate in the formation of scabs or scales, which are 
very persistent, and are finally succeeded by small, depressed, and 
copper-colored cicatrices, which are not permanent. Syphilitic 
vesicles are almost always accompanied by some other specific 
eruption, as erythema, papules, or pustules. 

Syphilitic bull^ {Syphilitic Pemphigus and Rupid). — Two 
syphilitic affections of the skin are characterized at their com- 
mencement by the larger form of vesicles known under the name 
of bullae, viz., pemphigus, which is chiefly met with in infants 
affected with hereditary syphilis, and rupia. 

Pemphigus. — Pemphigus was unknown to the older writers on 
venereal, and has only attracted attention since the commencement 
of the present century. In 1834, Krauss 1 collected a large number 
of instances of this affection in infants, and carefully described its 
symptoms, but did not suspect that it was due to hereditary syphi- 
lis, as the researches of M. Dubois 2 have since rendered probable. 

The bullae of pemphigus are from half an inch to an inch or 
more in diameter, but are not greatly elevated above the surround- 
ing surface, owing to the fact that the sacs are not fully distended 
with fluid; their outline is circular or ovoid; they rest upon a 

1 De Pemphigo neonatorum, Bonnae, 1834. 

2 Bulletin de l'Acad. Nationale de Med., 1851, t. xvi. 

36 



562 SYPHILITIC AFFECTIONS OF THE SKIN. 

violet- colored base which extends for a short distance beyond the 
elevated epidermis; their contents consist of a serous, sero-puru- 
lent, or sero-sanguinolent fluid which is discharged by rupture of 
the sac; and the eruption generally terminates in desquamation, 
but sometimes in ulceration. 

In most cases of syphilitic pemphigus of hereditary origin, the 
eruption is present at birth, is confined to the palms of the hands 
and the soles of the feet, and is soon followed by the death of the 
infant. Eicord figures a case in which it covered the whole body. 1 
I have recently observed a case in private practice, in which this 
eruption appeared on the third or fourth day after birth, was seated 
upon the arms, abdomen, and thorax, and was followed during the 
third week by mucous patches about the buttocks and upon the 
internal surface of the cheeks. At the time of conception the 
father was under my care for secondary syphilis. The mother, so 
far as I can learn, has never manifested any syphilitic symptoms, 
although fear of exposing the father has prevented my making 
minute inquiry. The infant still lives (three months old), and its 
symptoms have disappeared under small doses of mercury with 
chalk. 

Notwithstanding the fact that in most cases of pemphigus neona- 
torum a syphilitic taint has been discovered in one or both parents, 
yet the mere presence of this eruption cannot, in the absence of 
other symptoms, be regarded as conclusive proof of the existence 
of hereditary syphilis, since it is possible that infants at birth may 
be affected with pemphigus of simple origin from which the specific 
form of the eruption cannot be distinguished by its outward ap- 
pearance. 

A few cases only of syphilitic pemphigus have been observed in 
the adult as the result of acquired syphilis, one of which is figured 
by Eicord in his Iconographie, PI. XXY. In this case the seat of 
the eruption was upon the soles of the feet, and in another case ob- 
served by Bassereau, it was upon the palms of the hands, showing 
the same predilection for these regions both in adults and infants. 
When occurring in the former, the prognosis is not at all of the 
same serious import as in the latter. 

Rupia. — Eupia is classified by some authors among the bullous 
and by others among the pustular eruptions. Strictly speaking, it 

1 Iconographie, PL XLVI. 



eupia. 563 

is undoubtedly entitled to the position assigned it in the present 
work, although in many instances the initial bulla escapes observa- 
tion and the eruption appears to emanate from a pustule. 

Unlike the preceding eruption of this group, syphilitic rupia is 
only met with in adults and as a symptom of acquired syphilis. 
Its usual mode of development is as follows: a reddish spot first 
appears which is somewhat tender upon pressure, and upon which 
the epidermis soon becomes elevated by an effusion of bloody 
serum ; the bulla thus formed is very transitory in its duration and 
has usually disappeared by the third or fourth day, by which time 
its contents have dried into a thin scab of a greenish yellow color, 
and an ulcer has formed beneath. By the gradual addition and 
desiccation of purulent matter this scab increases in height and in 
breadth, and assumes a very characteristic appearance; its base is 
circular or oval and enchased within the underlying ulcer; it often 
rises above the level of the surrounding integument in the form of 
a cone, the sides of which are uneven and stratified by the succes- 
sive layers of its formation ; its color is a mixture of brown and 
yellow, or is sometimes almost black ; and it is surrounded by an 
areola of a dark-red or copper hue. The ulcer beneath it is deep, 
and its edges abrupt and sharply cut. This eruption is said to be 
most frequent upon the lower extremities, although in cases of 
syphilitic origin I have quite as often met with it upon the upper. 
It may occur upon any part of the integument. 1 

Syphilitic rupia is very persistent. Fresh scabs and ulcers 
appear in the vicinity of those first formed, so that the various 
stages of the eruption may frequently be observed upon the same 
person. During the reparative process, if the scabs be allowed to 
remain undisturbed, the ulcer granulates up from the bottom, and, 
when at last the scabs, having become dry and brittle, fall off, may 
have already attained a higher level than that of the surrounding 
surface. The succeeding cicatrix is of a sombre red or copper 
color, abruptly depressed, and indelible. 

Syphilitic rupia is a late symptom of constitutional infection as 
shown by its usual concomitants, viz., affections of the bones and 
periosteum, syphilitic orchitis, deep tubercles of the cellular tissue, 
etc. It is an indication of a very low condition of the general sys- 
tem, and demands the most careful attention to the hygienic condi- 
tion of the patient, and, in most cases, the free use of tonics. 

1 Iconographie, PI. XXXII. 



564 SYPHILITIC AFFECTIONS OF THE SKIN. 

Syphilitic Pustules {Syphilitic Acne, Impetigo, and Ecthyma; 
Pustulo- Crustaceous Syphilitic Eruption). — The earlier writers on 
venereal included all eruptions upon the skin under the name of pus- 
tules, and made no attempt to discriminate the different forms which 
they assumed. Yet an examination of their writings shows that 
syphilitic eruptions were much more frequently pustular during 
the Italian epidemic and for some years afterwards than now ; and 
this might have been expected from the known severity of syphilis 
at that time, since it is especially in the graver cases of this disease 
that the tendency to the formation of pus is most marked. 

Syphilitic pustules may appear upon any portion of the integu- 
ment. A very common seat is upon the scalp, and the question, 
" Have you had any scabs in the hair ?" is very frequently put to a 
patient by an experienced surgeon in the investigation of a sus- 
pected case of syphilis. Commencing upon the head, pustules often 
extend to the face and other parts of the integument, particularly 
in anaemic constitutions and in those cases in which the disease is 
peculiarly virulent. In some instances the lower extremities are 
chiefly affected. As in several other of the syphilodermata, the 
anatomical seat of the eruption appears to be in the hair follicles. 

Syphilitic pustules may assume the form of acne, impetigo, or 
ecthyma, which, in respect to frequency, are in an inverse order to 
the one here mentioned ; acne being the least and ecthyma the most 
frequent. 

Syphilitic Acne. — In this form, the pustules are of small size, 
generally acuminated, seated upon a prominent base, show but little 
tendency to spread, and remain stationary for several weeks before 
becoming covered with scabs, which are small, dry, and of a gray- 
ish or yellowish-brown color. The papule or plane surface left by 
the falling of the scab often takes on slight desquamation, and is of 
a more characteristic copper color than the preceding pustule. In 
some cases a superficial ulcer is formed. 1 

Unlike its analogue among the common affections of the skin, 
syphilitic acne is not limited to the superior parts of the body but 
may extend to the lower extremities, and may even be confined to 
the latter region ; and this fact is of the first importance in estab- 
lishing the diagnosis. When seated upon the face, back, or anterior 
portion of the thorax, the specific often bears a close resemblance 
to the simple eruption for which it may readily be mistaken. It is 

1 Iconographie, PI. XXVII. 



SYPHILITIC IMPETIGO. 565 

to be distinguished by the papular elevation left by the falling off 
of the scab, by the copper color of its later stages, and by the coex- 
istence of other syphilitic symptoms which generally belong to the 
earlier period of constitutional infection, since, in most cases, syphi- 
litic acne appears within a few months after contagion. 

Syphilitic Impetigo. — The pustules of syphilitic impetigo are flat, 
of variable size, and either isolated or in groups ; their base is either 
somewhat elevated and of a coppery red color, or sunken within a 
prominent border of the same aspect. An important feature is the 
color of the scabs, which are of a grayish or greenish-yellow hue. 

This eruption is frequently observed upon various portions of 
the face, more particularly around the alse nasi, at the commissures 
of the lips, and in the beard 1 and eyebrows, and is also met with 
upon the trunk, scrotum, and the upper and lower extremities. 

Syphilitic impetigo, when situated upon the labial commissures 
or around the nasal orifices, 2 presents a very characteristic appear- 
ance, which is not observed in any eruption of simple origin. The 
integument beneath is superficially ulcerated and generally vege- 
tates above the surrounding surface, while the summits of the 
granulations are covered with small yellowish scabs, and the patches 
tend to arrange themselves in circles or parts of circles, which are 
surrounded by a prominent border or copper-colored areola. At the 
commissures of the lips they are frequently continuous with mucous 
patches of the mucous membrane within the mouth. Upon other 
portions of the face it is sometimes difficult to distinguish syphilitic 
from common impetigo. 

When seated upon the scalp, forehead, thorax, and extremities, 
the pustules may be scattered or in groups, and often rest upon a 
hard, elevated, and dark red base ; while the scabs are of a greenish- 
yellow color, and the integument beneath is ulcerated. As a general 
rule these ulcerations are deeper and more extensive the longer the 
time which has elapsed since contagion. 

The French have given the name of " pustulo-crustaceous" to a 
form of impetigo, which is only met with as a late symptom of 
constitutional syphilis. The pustules are large and arranged in 
circles, and, the ulcers becoming continuous by gradual exten- 
sion, circular patches are formed covered with yellowish scabs 
which are most prominent around the margin, and surrounded by 
an areola of a dull red color. The cicatrices are excavated, at first 

1 Iconographie, PI. XLV. 2 Iconographie, PI. XLIL, Fig. 4. 



566 SYPHILITIC AFFECTIONS OF THE SKIN. 

red and afterwards of a dull white color, and resemble those pro- 
duced by a deep burn. 

Syphilitic Ecthyma. — Syphilitic ecthyma, the most frequent of all 
the pustular syphilodermata, consists of an eruption of that form of 
pustules known by the name of " phlyzacious," a term applied by 
Willan to " pustules of a large size, raised on a hard circular base 
of a vivid red color, and succeeded by a thick, hard, dark-colored 
scab." Like ordinary ecthyma, it may affect all parts of the body 
and especially the lower extremities ; but unlike the non-specific 
eruption, it is very frequent upon the hairy scalp, where it may 
often be observed at the same time that the trunk is covered with 
syphilitic roseola or papules. 

An eruption of ecthyma commences with the appearance of red 
and indurated spots upon the skin, the centre of which by the second 
or third day is elevated by an effusion of pus, which rapidly spreads 
until it covers the whole of the inflamed surface ; the epidermis is 
soon ruptured, and the pus which escapes concretes into a broad 
brownish scab. 1 

The subsequent course of the eruption presents two varieties. 
In one, the tendency of the pustule and subjacent ulcer to increase 
in size and in depth is but slight, while in the other it is strongly 
marked ; and hence two forms of ecthyma are admitted, viz., the 
superficial and the deep, the former of which is an early and the 
latter a late symptom of constitutional infection. 

In the superficial variety, the scab first formed does not materially 
increase in breadth or in height, and its removal exposes a super- 
ficial ulceration which soon heals, leaving a shallow and permanent 
cicatrix which is pitted like the scar of vaccinia. 

In the deep variety, the scab increasing in extent and in height 
by the constant addition of purulent matter, protrudes above the 
surface, is sometimes depressed at the centre, and is made up of 
consecutive rings; in most cases it slightly overlaps the edges of 
the ulcer, while in others it is set within the cavity, a portion of 
which may even be exposed in consequence of the scab not being 
sufficiently large to cover it. If the scab be removed, the ulcer is 
found to penetrate deeply into the tissues beneath ; its edges are 
abrupt and its floor covered with a grayish secretion. The cica- 
trices which are left after the healing of the ulcers, are depressed, 

1 Iconographie, PI. XXVI. ter et quater. 



SYPHILITIC ECTHYMA. 567 

at first of a dark-red color and afterwards of a dull white, never 
entirely disappear, but are not pitted like those of the superficial 
variety. 

In some cases the pustules of syphilitic ecthyma, although at first 
distinct, are collected together in groups, when they may unite and 
give rise to a large scabby patch, which constantly tends to extend 
over a still larger surface, and the outline of which exhibits the 
circular form so frequently seen in syphilitic eruptions. These 
patches, like those of impetigo, which they resemble, are known 
by the name of "pustulo-crustaceous." 

An eruption of syphilitic pustules is often preceded by the com- 
bination of symptoms which I have described under the head of 
syphilitic fever. These symptoms, however, are of short duration, 
but the eruption itself is very persistent, and, under the best directed 
treatment, may last for several months. 

The superficial varieties of syphilitic pustules belong to the early, 
and the deep to the late periods of constitutional infection. The 
former are more generally diffused over the integument than the 
latter. Bassereau lays down the rule, that a pustular eruption 
occupying different parts of the body, is rarely met with at a later 
period than six months after contagion, unless delayed by treat- 
ment, and calls attention to a remark made by Gabriel Fallopius 
in the sixteenth century to the effect that " when the pustules in- 
vade the whole body, and when they are developed in the hair and 
beard, it is a sign that the French disease has been contracted with- 
in five or six months." 

On the other hand, the deep varieties of syphilitic pustules occupy, 
in most cases, but one or two regions, are much more destructive 
in their action, are only met with at a late period of constitutional 
infection, and are consequently attended by symptoms belonging 
to a more advanced stage of the disease than the superficial varie- 
ties. For instance, syphilitic orchitis, nocturnal pains in the shafts 
of the bones, and exostoses rarely, if ever, accompany the super- 
ficial, but are common with the deep forms of syphilitic pustular. 

In a previous chapter, attention was called to the fact that the 
degree of ulcerative action attending an infecting chancre may be 
taken as indicative of the general condition of the system and of 
the probable character of the general symptoms which are likely 
to follow. A similar rule holds good in the syphilodermata. A 
tendency to the pustular forms of eruption indicates a degree of 



568 SYPHILITIC AFFECTIONS OF THE SKIN. 

constitutional cachexia that will favor the evolution of tertiary 
syphilis in deep and important organs ; the prognosis, therefore, in 
the syphilitic pustulse is decidedly unfavorable. Of 42 persons 
observed by Bassereau who were afflicted with deep ulcerations of 
the fauces, suppurating tubercles of the cellular tissue and caries of 
the bones, 27 had previously had a pustular syphilitic eruption. 

Syphilitic Tubercles. — Tubercles, like papulae, are solid eleva- 
tions of the derma, but differ from the latter in their larger size, 
the greater depth to which they involve the tissues, the later period 
of their development, and their marked tendency to ulceration. 
The name itself is an unfortunate one, since it is also applied to the 
pathological deposit of phthisis, to the gummy tumors of tertiary 
syphilis, and, very incorrectly as I shall hereafter show, to mucous 
patches or condylomata ; but it is too commonly used to be laid 
aside, and I can only caution the student not to confound the 
various lesions to which the term is applied. 

Tubercles are rarely, if ever, the first manifestation upon the 
skin of constitutional infection. It may be laid down as a rule to 
which there are probably no exceptions, that they have in all 
cases been preceded by some one of the more superficial syphi- 
lodermata, as erythema or papules. They are to be ranked among 
the late symptoms of syphilis, and may occur ten, twenty, or even 
forty years after contagion. The following table exhibits the time 
of development of syphilitic tubercles in 54 cases observed by 
Bassereau : — 

The eruption appeared — ■ 

11 months after contagion in 1 case. 13 years after contagion in 1 case. 



1 


year 


tt 


i tt 


5 


cases. 


14 


2 


years 


a 


t u 


3 


a 


17 


3 


ik 


it 


t tt 


5 


n 


18 


4 


a 


a 


t it 


6 


a 


20 


5 


tt 


it 


t tt 


7 


a 


22 


6 


a 


« 


t a 


3 


a 


26 


7 


it 


(( 


t a 


2 


a 


30 


9 


a 


<( 


a tt 


3 


ti 


40 


10 


a 


tt 


t it 


2 


a 




12 


it 


it 


t it 


2 


a 





Total 



2 


cases. 


1 


case. 


2 


cases. 


5 


a 


1 


case. 


1 


a 


1 


a 


1 


it 


54 


cases. 



In many of these cases mercurials had been administered, and 
hence these dates do not indicate the normal period of development 
of tubercles when not delayed by treatment. This table, however, 



SYPHILITIC TUBEKCLES. 569 

is sufficient to show that a tubercular eruption is far more tardy 
than the superficial syphilodermata, as erythema and papules, 
which are never under any circumstances observed so long after 
contagion as in many of the above instances. 

Syphilitic tubercles may be seated upon any portion of the in- 
tegument. It is rare for them ; however, to be spread over the 
whole surface. They are commonly confined to one, two, or three 
regions, and if they involve a larger number, it is by slow and 
gradual progression. Their most frequent seat is upon the face, 
where they often attack the lips and alae nasi, and may occasion 
their total destruction. Another common site is the lower ex- 
tremities, where they often give rise to ulcers of long duration and 
very intractable. 

Of 70 cases observed by Bassereau — 

The face was involved in . . . . . . . .26 

" body " " 22 

" upper extremities were involved in . . . .16 

" lower " " " " ..... 14 

" hairy scalp was involved in ...... 5 

" neck was involved in ....... 8 

" back of the hands was involved in 1 

The anatomical seat of tubercles has been carefully studied by 
the same author who states that, in many cases, the changes upon 
which they depend appear to be confined to the neighborhood of 
the hair follicles ; while, in others, the cellular conical protuberances 
upon the internal surface of the derma are the primary seat of the 
disease, the skin becoming thinned as the tubercle is developed, 
and finally ulcerating and giving exit to the adventitious deposit. 
Again, tubercles may commence as small tumors in the sub-integu- 
mentary cellular tissue, become adherent to the surface, and in this 
case also give rise to ulcers. 

Syphilitic tubercles may be divided into two classes : 1. Those 
which terminate in desquamation or resolution ; and, 2. Those 
which suppurate and form ulcers. 

Tubercles belonging to the first class are hard, shot-like bodies, 
occupying the whole thickness of the skin, above which they pro- 
ject to a variable extent. 1 They are "isolated or more frequently 
in groups, and either flat, conical, or hemispherical. Their size 
varies from that of a small shot to a cherry. Their color is usually 

J Iconographie, PI. XXV., Fig. 1, and PI. XXVIII. 



570 SYPHILITIC AFFECTIONS OF THE SKIN. 

a dark red, though in a few instances, and especially in persons of 
a sallow complexion, it does not greatly differ from that of the 
normal integument. They are sometimes tense and shining, or 
covered with thin scales which fall off and give place to others, or 
surmounted by scabs which are the product of an effusion of serum 
beneath the epidermis without deep ulceration. When aggregated, 
they form groups which are generally circular, but sometimes 
irregular. The centre of the patch is often free, covered with thin, 
epidermic scales formed upon the site of tubercles which have now 
disappeared, and of a darker color than the healthy skin. The 
prominent border may be composed of distinct tubercles, which 
in other cases are so approximated as to form one continuous cir- 
cular elevation ; and the patch constantly tends to enlarge by the 
subsidence of the old tubercles and the development of new ones 
external to the first. In some instances, instead of forming wheels, 
tubercles are collected into irregular masses, in which, however, 
a tendency to a circular form is still manifest, and, if closely 
approximated, the general thickening of the skin beneath may 
elevate the patch to a considerable distance above the surrounding 
surface. 

These various forms are very slow in their progress and decline, 
and often persist for many years. 

Ulceration may commence in the second class of tubercles in 
several ways. It may take place beneath the thin scab formed 
upon tubercles which have for a time been entirely dry ; or it may 
attack the summits of others at a very early stage of their existence, 
or, again, it may commence in the interior of small tumors developed 
in the cellular tissue beneath the skin. In whichever way origi- 
nating, it often progresses until it completely destroys the tubercles, 
of which no traces remain except an open sore covered by a thick 
scab. 

As in the dry variety tubercles when ulcerated may be arranged 
in the form of wheels or circles, inclosing a sound portion of the 
integument and constantly enlarging by peripheral extension ;* or 
they may consist of elongated or spiral bands, or assume various 
shapes, as figures of eight, etc. In most cases there is only one 
ulcerated patch ; in others, there are several ; and in others still, 
the whole surface of one or more portions of the body is involved, 
as frequently occurs upon the face. 

» Iconographie, PI. XXIII. et XXIII. bis, Fig. 2. 



SYPHILITIC TUBERCLES. 571 

The depth of the ulceration varies in different cases ; when super- 
ficial, the scab is thin, and the subsequent cicatrix is quickly effaced ; 
when deep, the scab is thick, of a greenish-yellow color, and either 
protuberant above the surface or sunken within the borders of the 
ulcer, and the scar is indelible. These ulcers sometimes become 
serpiginous and creep over a large extent of surface, healing in 
one direction while they advance in the opposite ; causing but little 
detriment if superficial, but occasioning fearful ravages if they 
involve the whole thickness of the derma. 1 Serpiginous ulcers 
originating in tubercles are often seen in the neighborhood of the 
larger joints, and also upon the back, thorax, abdomen, and neck. 
They may generally be distinguished from serpiginous chancres by 
their situation at a distance from the genital organs, by the inter- 
position of sound portions of the integument between the ulcers, 
by the greater consistency of their secretion, the thickness of the 
scabs, and the history of the case. 2 A variety of tubercles, known 
as " perforating," sometimes attacks the ala? nasi, in the substance of 
which small tumors are formed, rapidly suppurate and burst, and 
give rise to an eroding ulcer which may destroy nearly the whole 
of the nasal organ. 3 Lupus exedens, which closely resembles this 
form of tubercles, commonly occurs before the age of puberty, is 
attended by a greater degree of engorgement of the neighboring 
tissues, and its ravages, after many years' duration, are limited to a 
small extent of surface. 

Syphilitic tubercles have been mistaken for cancer from which 
they differ in their softer consistency, in the absence of lancinating 
pains, and in the integrity of the neighboring ganglia. 

The cicatrices left by this eruption, when the ulceration has been 
deep, are generally depressed, of a coppery-red color which subse- 
quently gives place to a dull white, and either smooth or traversed 
by bands of modular tissue. Bassereau has called attention to the 
numerous depressions which exist upon the general surface of the 
cicatrix and which mark the site of the tubercles of which the 
patch was originally composed. This character is not found in the 
scars of any eruption except those of syphilitic tubercles. In most 
cases, also, the cicatrices of this eruption may be recognized by 
their general circular outline or by the segments of circles which 
are apparent upon their borders. 

1 Iconographie, Pis. XXXVI. and XXXVII. 2 See p. 388. 

* Iconographie, PL XIX. 



572 SYPHILITIC AFFECTIONS OF THE SKIN. 

Ulcerated syphilitic tubercles are never accompanied by the 
superficial syphilodermata. Their most frequent concomitants are 
syphilitic orchitis, affections of the periosteum and bones, and 
syphilitic cachexia. 

Ulcees. — Cullerier, the elder, and Alibert admitted still another 
class of syphilitic eruptions which they called " the ulcerating," but 
ulcers originate either in a vesicle, pustule, or tubercle, and have, 
therefore, been included by more modern authors among the syphilo- 
dermata which have already passed under our notice. It is not 
necessary to repeat at length the characters pertaining to syphilitic 
ulcerations, according as they arise from one or the other of these 
initial lesions. I will simply recall to the mind of the reader, that 
when commencing with a vesicle, ulcers are superficial and are 
generally scattered in large numbers over a considerable extent of 
surface ; that those from pustules, when the eruption occurs at an 
early period of infection, are also numerous but deeper than the 
former ; while in a later stage, both the ulcers of pustules and of 
tubercles are more limited and more destructive in their action. 
In many cases, the coexistence of the various stages of the eruption 
in the same person will facilitate the diagnosis. 

Ulcers of the skin may also be due to the suppuration and open- 
ing of deep tumors of the cellular tissue and to syphilitic affections 
of the periosteum and bones, but with care may be distinguished 
from those commencing in the skin itself. 

Tkeatment. — Little need be added to the remarks already made 
upon the treatment of general syphilis with reference to the special 
treatment of the syphilodermata. As in other syphilitic affections, 
our chief remedies are mercury and iodide of potassium, and the 
only embarrassment likely to occur is to know when to employ 
the one and when the other. No great difficulty, however, need be 
experienced upon this score, provided the fact be borne in mind 
that the superficial eruptions which terminate in desquamation, 
belong to the secondary stage of syphilis in which mercury is re- 
quired, and that the deeper eruptions, attended by suppuration and 
ulceration, belong to the stage of transition or to the tertiary period, 
in both of which iodine should precede or accompany mercurials in 
the treatment. Indeed, supposing a case of syphilitic eruption to be 



TKEATMENT. 573 

placed in the hands of a practitioner totally incapable of assigning 
it its proper position npon a scientific chart of the syphilodermata, 
simple attention to the absence or presence of suppuration and 
ulceration might enable him in most cases to determine the proper 
course of treatment to be pursued ; since he could readily recognize 
the broad features which distinguish the non-ulcer ative and the 
ulcerative affections of the skin; the former class including ery- 
thema, papules, squamae, and vesicles, which are either entirely dry 
or are attended by a serous or thin sero-purulent secretion from a 
superficial erosion ; and the latter embracing pustules and tubercles 
which give rise to ulcers varying in extent and depth. Pustules 
may, indeed, occur at an early period of infection in debilitated 
subjects and exhibit a marked tendency to ulcerative action, but 
such cases do not well support the use of mercury, so that for all 
practical purposes the above distinction holds good. 

Another indication for the choice of remedies may be found in 
the extent of surface covered by the eruption, which, in erythema, 
papules, vesicles, and the early forms of pustules, is much more 
extensively diffused than in late pustules and tubercles. 

But by far the most valuable assistance is to be derived from 
the character of the syphilitic symptoms which almost always 
accompany the syphilodermata, and which have been particularly 
mentioned in the preceding pages in connection with each form of 
eruption. It is unnecessary at present to do more than recall to 
mind the syphilitic fever, headache, rheumatic pains, impetigo ca- 
pitis, alopecia, engorgement of the cervical ganglia, and mucous 
patches, one or more of which usually accompany the earlier 
syphilodermata, and the osteocopic pains, affections of the bones 
and periosteum, and orchitis, which attend the later eruptions. 

With regard to the external treatment of the syphilodermata, 
a simple warm bath two or three times a week, already recom- 
mended in the general treatment of syphilis for the purpose of 
favoring cutaneous secretion, will be found to exert a beneficial 
influence, especially upon those eruptions which are extensively 
diffused over the surface, and the effect may be increased by the 
addition of gelatine, bran, starch, or one of the alkalies ; but medi- 
cated baths are, I suspect, more frequently recommended in books 
than employed in practice, at least in this country. Baths of cor- 
rosive sublimate containing half an ounce of the bichloride and an 



574 SYPHILITIC AFFECTIONS OF THE SKIN. 

ounce of muriate of ammonia to each bath, have been highly praised 
by Trousseau 1 and others. 

In most cases it is not desirable to remove the scabs which cover 
many of the late syphilitic eruptions, since they serve to protect 
the sore beneath from friction and abrasion, and accomplish this 
purpose better than any artificial dressing. As the ulcers heal 
under the administration of internal remedies, the scabs fall off and 
expose a surface which is nearly, if not quite cicatrized. 

In some cases, however, as in tubercular eruptions upon the face, 
squamge upon the palms of the hands, and open ulcers upon various 
parts of the body, a regard for external appearances or the comfort 
of the patient requires the use of topical applications, as ointments 
of the red precipitate, nitrate or iodide of mercury, or iodide of 
sulphur ; lotions containing aromatic wine, the potassio-tartrate of 
iron, chlorinated soda, or the compound tincture of benzoin or the 
emplastrum hydrargyria or emplastrum de Vigo cum mercurio which 
is in much favor with the French, especially in syphilitic eruptions 
upon the face. An excellent treatment of sluggish syphilitic ulcers 
is to sprinkle their surface with iodine in powder and cover them 
with dry lint and a bandage. A favorite application with Eicord, 
is lint soaked in the following solution of iodine. 

fy.. Potassii iodidi gr. xv. 
Tinct. iodinii ^iss. 
Aquae gvj. 
M. 

I have found equal parts of glycerin and the oil of cade an ex- 
cellent local application to the squamous eruption upon the palms 
of the hands ; or when there is much surrounding inflammation the 
following formula may be used : — 

I£. Oil of cade gij. 

Glycerin 3 v. 

Solution of subacetate of lead 5j« 
M. 



Therapeutique, 5eme ed., i. 229. 



SYPHILITIC ALOPECIA. 575 



CHAPTER VIII. 

SYPHILITIC AFFECTIONS OF THE APPENDAGES 
OF THE SKIN. 

Alopecia. — There are two forms of alopecia dependent upon 
syphilis and appearing at different stages of constitutional infection. 

The first form is much more frequent than the second, and is, 
indeed, one of the most constant of the category of early symptoms 
which should ever be borne in mind by the surgeon who treats 
venereal diseases, in order that he may be able to recognize the 
first evidence of vitality in the syphilitic virus after the period of 
dormancy which follows the evolution of the chancre. No apology 
will be necessary to the professional reader if I add, that one can- 
not but admire the wonderful order and regularity in the develop- 
ment of even so loathsome a disease as syphilis, nor fail to take 
pride in being able to detect the presence of this destructive poison 
from so slight an indication as the unwonted falling of the hair, 
enlargement of the cervical ganglia, nocturnal headache, redness of 
the fauces, pustules upon the scalp or a few blotches upon the body. 
It is fortunate both for the physician and patient that he whose duty 
it is to treat the sad consequences of vice, can yet find interest and 
pleasure in his occupation. 

The falling out of the hair is a very early symptom of constitu- 
tional infection, and may take place before the appearance of any 
eruption upon the skin, in conjunction with those symptoms which 
are known under the name of syphilitic fever. It varies greatly 
in degree in different cases ; in some it is so slight as not to attract 
attention unless discovered by the surgeon, who finds on passing 
his fingers through the hair and exerting slight traction upon it 
that it comes out with unusual facility ; while in others the hair 
falls out by handfuls, especially when there is an abundant erup- 
tion of pustules or pityriasis upon the scalp. Nor is this symptom 
always confined to the head ; in many cases it also affects the eye- 
brows, which may become so nearly bald as to render the patient 



576 APPENDAGES OF THE SKIN. 

conspicuous, especially if his hair be light colored. In rare instances 
the eyelashes and the beard fall out in a similar manner. 

This early form of alopecia is always amenable to treatment, and 
the patient may be assured that there is no danger of his becoming 
permanently bald. We cannot, indeed, arrest the falling out of 
the hair at once, but so soon as the system is brought under the 
influence of mercury, the tendency ceases, and the hair is repro- 
duced. In those persons who have taken mercurials for their infect- 
ing chancre, this symptom is often absent. 

There is another form of alopecia which is mentioned by the 
earlier writers on syphilis as having been extremely common in 
former years, but which is now very rare. It is characterized by 
the disappearance of every vestige of hair from the whole integu- 
mental surface, is only met with in the later stages of syphilis and 
generally in conjunction with syphilitic cachexia, and is almost 
always incurable. 

Treatment. — The early form of alopecia is speedily arrested by 
the constitutional treatment of the syphilitic diathesis, and there is 
no necessity for resorting to the use of remedies especially directed 
to the reproduction of the hair. To meet the wishes of patients, 
however, it is often desirable to prescribe some local application 
which may not perhaps be entirely without effect in hastening the 
appearance of a new growth. For this purpose pomades or washes 
containing a stimulant, as castor oil or tincture of cantharides, are 
commonly employed. The following formulas may be recom- 
mended : — 

fy.. Aquae Colognae ^j. 

Olei ricini §j. 

Spiriti recti 5J. 
M. 

R. Aquae ammoniae !§j. 
Olei ricini gij. 

" olivae^j. 

" terebinthinae 5ij- 

" bergamii, 

" jasmini, aa q. s. 
M. 

The following is a very pleasant preparation : — 

I£. Spiriti ammoniae aromat. §j. 

Glycerinae §ss. 

Tinct. cantharidis ^iss. 

Aquae rosae 3vij. 
M. 



ONYCHIA. 577 



The following is known as Dupuytren's pomade :- 

I£. Medullas ossium bovis §j. 
Tinct. cantkaridis §j. 
Digest to a proper consistency and add — 

Plumbi acetatis 5.1- 
Balsauii Peruviani §iij. 
Olei caryophylli, 
" canellae, aa rr\xv. 



M. 



Olei olivae ,^ij. 
Adipis §ij. 

Hydrarg. oxidi rubri levigati 5j- 
Olei amygdalae ^ ss. 
Glycerinae 5j« 



M. 



Either of the above preparations may be used once or twice a 
day. Fine-toothed combs and soap of every kind should be avoid- 
ed, and the scalp be cleaned, if required, with a solution of borax 
or with the yolk of an egg and warm water. 

In the late form of alopecia the iodide of potassium should be 
employed internally in conjunction with mercury. 

Onychia. — Syphilitic onychia is a much rarer affection than the 
preceding, and appears at a later period of constitutional infection. 
In the cases I have met it has coincided with a pustular or squa- 
mous eruption. The nails of the fingers are much more frequently 
affected than those of the toes. I have at present under my charge 
a man of dissipated habits who contracted syphilis six months ago, 
and who now has condylomata about the anus and upper and inner 
parts of the thighs, mucous patches within the mouth and upon 
the prepuce, a pustular eruption in circular patches upon the scalp 
and breast, lepra upon the palms of the hands, and all of whose 
finger nails are affected with onychia while the nails of the toes are 
intact. 

In this affection, as most frequently observed, the integument 
around the base of the matrix becomes swollen, red, and tender on 
pressure, is detached from the nail and its epidermis exfoliates. 
The nail itself loses its vitality, becomes thickened, opaque, 
roughened, dry, and very friable, and is often deviated from its 
normal direction. In a more advanced stage of the disease, ulcera- 
tion of the matrix takes place, and pus may be made to exude by 
37 



578 APPENDAGES OF THE SKIN. 

pressure upon the elevated border; sometimes fungous granulations 
spring up as in ingrowth of the nail, 1 and in extreme cases the 
whole matrix is destroyed, the nail falls off and is not reproduced. 
Treatment. — Except under the circumstances just mentioned, 
syphilitic onychia yields to mercury and the nail resumes its 
normal characters. Under the administration of specific remedies 
it is interesting to watch the new and tender growth springing up 
from the matrix and pushing before it the remnants of the old nail 
deformed by disease. Lotions of corrosive sublimate and oint- 
ments of the red oxide and other preparations of mercury are 
recommended, but I have never found it necessary to resort to 
other than general treatment. Diday recommends that the patient 
should wear upon the affected finger a cot the extremity of which 
is filled with emplastrum de Yigo cum mercurio rubbed up with a 
sufficient quantity of olive oil to give it a semi-liquid consistency. 3 

Whitlow. — Syphilitic panaris may be here considered for the 
sake of convenience, although it is not properly included among the 
syphilitic affections of the appendages of the skin. Its symptoms 
do not materially differ from those of the common affection known 
under the name of whitlow or felon, for which it is usually mis- 
taken ; but it more frequently leaves the finger in a state of chronic 
inflammation and engorgement and gives rise to fistulae which are 
extremely difficult to heal if the cause of the disease be not recog- 
nized. Such mistakes are the more liable to occur because this may 
be the only existing symptom of constitutional infection, or its only 
concomitant a gummy tumor at a distance and concealed by the 
patient from the surgeon. Like ordinary whitlow, it arises either 
in the periosteum, sheaths of the tendons or cellular tissue covering 
the phalanges. It is usually observed in the tertiary period of the 
disease, and is to be treated by iodide of potassium. An interest- 
ing case of this affection has recently occurred at Nekton's clin- 



ique. 3 



1 See Ricord's Iconographie, PI. XLII., Fig. 3. 

2 Gaz. Med. de Lyon, No. 2, 1860. 

3 Gaz. des Hop., March 3, 1860. 



MUCOUS PATCHES. 579 



CHAPTER IX. 

MUCOUS PATCHES. 

"The name 'mucous patch' is applied to a lesion peculiar to 
syphilis, consisting of elevations of a more or less decided rose 
color, frequently rounded in form, the surface resembling a mucous 
membrane, and situated in the neighborhood of the outlet of mu- 
cous canals, especially around the genital organs and anus, upon 
the mucous membrane of the mouth, and sometimes upon other 
parts of the body, more particularly at the base of the nails and 
wherever the reflection of the integument upon itself forms natural 
folds in the skin." 1 

This affection is one of the earliest and most frequent secondary 
manifestations of syphilis, and is therefore one with which the stu- 
dent of venereal should be perfectly familiar ; unfortunately obsta- 
cles have been placed in the way of acquiring a knowledge of it 
by the confusion which has been introduced in its classification, 
and in the terms which have been applied to it. Different authors, 
according to the views they have entertained of its nature, have 
described it among tubercles, pustules and papules, and have 
called it by the corresponding names of " mucous tubercle," " pus- 
tule" or "papule." But the first two of these terms are entirely 
inappropriate, since it does not resemble syphilitic pustules or 
tubercles in its time of development, its symptoms, course, or ter- 
mination. The name mucous papules is less objectionable, since 
this lesion consists in most instances of a development of the 
papillae forming broad elevations above the surrounding surface ; 
but it is not always elevated, and may even be excavated, and it is 
moreover so distinct in its characters from ordinary papules, and 
of such importance as a symptom of constitutional infection, as 
to entitle it to the separate name adopted by MM. Deville and 
Davasse, which I shall here retain. 

1 Davasse and Deville, Des Plaques Muqueuses, Arch. Gen. de Med., 1845, t. 
ix. et x. 



580 



MUCOUS PATCHES. 



As stated in the definition given by the authors just mentioned; 
the seat of this lesion includes the outlet of mucous canals, and 
those portions of the external integument which are maintained 
by contact in a constant state of warmth and moisture, and are 
thus very nearly in the condition of mucous surfaces. Some idea 
of its comparative frequency in these various regions may be 
obtained from the following tables : — 

In 130 men observed by Bassereau, mucous patches were found — 



Around the anus 
Upon the tonsils 
" " scrotum 



" " lips . 

" " glans and prepuce 

" " velum palati 

" " tongue 

" " pillars of the soft palate 

" " internal surface of the cheeks 
Between the toes .... 
In the fold between the scrotum and thigh 
At the nasal orifice .... 
On the posterior wall of the pharynx 
At the base of one of the toe nails . 
" " meatus urinarius . 

In the axilla 

Upon the gums 

Covering the thighs in an infant three months old 

In 186 women observed by Davasse and Deville, mucous patches 
were found — 

Upon the vulva ........ 174 times. 

" " anus . .59 

" " perineum . 40 



110 times. 
100 
66 
55 
28 
27 
18 
17 
11 
11 

5 

2 

2 

2 

once. 



" " nates and upper and inner parts of the thighs 

" " tonsils 

" " nostrils 

" " tongue ....... 

" " toes 

" " face 

" " umbilicus ....... 

Around the nails 

Upon the ears ........ 

" soft palate 

" inguinal fold ...... 

" neck 

" nipple ....... 

" cervix uteri ...... 



38 
19 

8 

6 

5 

5 

3 

2 

2 

2 

2 

once. 



MUCOUS PATCHES. 581 

It tlms appears that the most frequent seat of mucous patches in 
men is around the anus and within the mouth, and in women upon 
the vulva. It has been asserted that they are much more frequent 
in the latter than in the former sex, but the difference is probably 
not so great as has been supposed. There is certainly no more 
common symptom in male patients affected with syphilis. They 
are also present in most cases of hereditary syphilis in infants, and 
in consequence of the moist condition of the integument at this 
early age, are not confined to the regions above mentioned but may 
be scattered over the whole surface of the body and especially the 
nates and thighs. 

The development of mucous patches is everywhere favored by 
inattention to cleanliness, and in the mouth by the use of tobacco, 
either by smoking or chewing; in men who are habituated to this 
practice, they constitute one of the most persistent and troublesome 
symptoms we have to deal with, and in dirty prostitutes of the 
lower class they are equally abundant and obstinate about the 
genital organs. At Belle vue Hospital, in this city, I have seen 
some remarkable instances of mucous patches upon the walls of 
the vagina and cervix uteri, the consequence of syphilis and filthy 
habits. 

Mucous patches vary in appearance according to their situation. 
The chief points of difference are found between those seated upon 
the external integument and those upon membranes which are 
strictly mucous. 

The former, which are met with for the most part around the 
anus and genital organs in the two sexes, consist of rounded disks, 
either single or aggregated, of a reddish or grayish color, granu- 
lated and elevated to the height of about a line above the integu- 
ment upon which they appear to be superimposed. Their appear- 
ance is so peculiar, that when once seen it cannot be forgotten. 
Let the student who has never had the opportunity to observe 
them consult the admirable representation of them in Eicord's 
Iconographie, PI. XVII. 

Their mode of development is as follows : A red spot first ap- 
pears upon the skin, and a slight effusion takes place beneath the 
epidermis — sufficient to loosen it from the derma but not to raise 
it in the form of a vesicle or bulla ; the epidermis is removed by 
friction or falls off, and exposes a raw surface upon which a moist, 
grayish pellicle is soon formed; the surface is elevated by hyper- 



582 MUCOUS PATCHES. 

trophy of the superficial layers of the skin and gives rise to the 
broad, flat, wart-like disks above referred to. 

Another and a very singular mode of origin of mucous patches 
is from the surface of an infecting chancre, which, during the repar- 
ative process, may granulate above the surrounding integument, 
and become covered with a thin, translucent and grayish pellicle. 
This remarkable transformation of a primary into a secondary 
symptom has already been described in the chapter upon chancres. 
Numerous instances of its occurrence upon the genital organs are 
recorded, and I have myself met with several. Bassereau relates 
an interesting case in which it took place upon the lower lip. 1 

When originating in the manner last mentioned, mucous patches 
are seated upon an indurated base, but otherwise the tissues be- 
neath them are found on pressure to retain their normal suppleness. 
Contrary to the statements of some authors, they never present the 
copper color of other syphilitic eruptions, but are either of a reddish 
or grayish white color. If the patient happen to be jaundiced, 
the pellicle covering them may be tinged with yellow. They are 
usually smeared with a very offensive muciform secretion, which is 
peculiarly unpleasant when the patches are seated in the neighbor- 
hood of the genitals, and I have repeatedly known the odor to be 
so strong as to pervade the room. In a few exceptional instances 
the patches are dry. 

Mucous patches readily become ulcerated. "When exposed to 
friction against the clothes or the opposed integument, the pellicle 
covering the patch is removed, and a red, superficial, but depressed 
ulceration takes the place of the elevated disk. Such is the origin 
of the raw surfaces frequently seen upon the sides and front of the 
scrotum in syphilitic patients. 

Ulcerated mucous patches upon the margin of the anus closely 
resemble ordinary anal fissures, from which they may be distin- 
guished by their more prominent and rounded edges, and by the 
grayish pellicle which is generally visible upon the sides of the cleft. 
When situated between the toes, their odor is particularly disgust- 
ing, and they often project upon the dorsum of the foot in the form 
of a crescent at the base of the interdigital sulci. Ulcerated and 
fissured mucous patches upon the margin of the anus, between the 
toes, or elsewhere, are called rhagades. 

1 Op. cit., p. 326. 



MUCOUS PATCHES. 583 

Condylomata upon the vulva are generally elevated and of a red- 
dish color, as is well represented in Eicord's Iconographie, PL XX. 
Those that I have seen within the vagina and upon the cervix uteri, 
have more closely resembled mucous patches upon the external in- 
tegument than those situated upon other mucous membranes, as, for 
instance, within the buccal cavity. Mucous patches upon the geni- 
tal organs in both sexes sometimes give rise to a discharge resem- 
bling gonorrhoea from the neighboring mucous membrane, which 
is not unfrequently observed about the time that early secondary 
symptoms appear, or when a relapse takes place in the constitutional 
disease. 

Unlike most syphilitic eruptions mucous patches are frequently 
attended by severe pruritus, especially when seated upon the scrotum 
or perineum, and when proper attention is not paid to cleanliness 
or the parts have become warm and moist from exercise or pro- 
longed contact in bed. The unquestionably contagious character 
of these lesions has been dwelt upon in another chapter. 1 

Mucous patches within the buccal cavity present a somewhat 
different appearance from those now described. Their most char- 
acteristic feature is the grayish-white color, appearing as if they 
had been pencilled over with a crayon of nitrate of silver, which 
has given them the name of " opaline patches." They are more 
irregular in their outline than condylomata, and unlike the latter 
are not, as a general rule, perceptibly elevated above the surface. 
In some cases, the adventitious deposit which gives them their 
grayish color and which is with difficulty removed, is confined to 
the irregular margin of the patch, while the centre remains sound ; 
and when presenting this appearance they have been compared to 
the track of a snail. 2 

The most frequent seat of this form of mucous patches is upon 
the internal surface of the lips and cheeks, upon the sides and 
dorsum of the tongue, upon the gums, tonsils, and soft palate. 
They rarely extend beyond the pillars of the fauces, although 
occasionally, as in two instances in Bassereau's table already 
quoted, they are seen upon the walls of the pharynx. 

A frequent situation is at the angle of the mouth, where they are 
often intersected by cracks and fissures, the sides of which present 
the characteristic grayish color of this lesion, and where they are 

1 See page 482. * Iconographie, PI. XX., bis. 



584 



MUCOUS PATCHES. 



continuous with small patches of impetigo upon the external integu- 
ment. Upon the dorsum of the tongue, their base is sometimes hard, 
indurated, and fissured ; or the pellicle which at first covers them 
may be rubbed off by the food, leaving a slightly depressed surface 
resembling an aphthous ulceration; or, again, they may granulate 
above the surface and form vegetations. When seated upon the 
tonsils, mucous patches are peculiarly exposed to irritation and ulcer- 
ation from friction of the food in deglutition, and ulcers are formed, 
attended by considerable inflammation and swelling of the surround- 
ing parts, and in which the characters of the original lesion are 
entirely lost. Deglutition is very much impeded, and the surround- 
ing inflammation may extend to the Eustachian tube and produce 
partial deafness. 

Bassereau states that mucous patches may react upon the neigh- 
boring lymphatic ganglia, in the same manner as syphilitic erup- 
tions situated upon the scalp, but only in case their development is 
attended by acute inflammation. Thus the submaxillary glands 
are frequently swollen from sympathy with mucous patches upon 
the fauces; and the inguinal glands may be enlarged in conse- 
quence of the presence of condylomata upon the scrotum, but the 
effect upon the latter is less readily perceived because they are gen- 
erally indurated from their anatomical connection with the primary 
sore. In two cases observed by Bassereau, in which the chancre 
was situated at a distance from the genital organs, the inguinal 
glands were enlarged in consequence of mucous patches in the last 
mentioned situation. This effect upon the ganglia is, however, ex- 
ceptional, and always consists of mere engorgement and never of 
induration. 

The following tables from the same author exhibit the period of 
development of this lesion after contagion when no treatment had 
been instituted, and also when mercury had been given for the 
primary sore: — 

In the former case, mucous patches appeared — 



On the 20th 


day 


after contagion in 


. 


1 instance. 


" " 29th 


« 


« ti U 


. 


1 


« 


From 1 to 2 


months after contagion 


in 


25 instances. 


» 2 " 3 


« 


u u 


k 


5 


« 


" 3 " 4 


it 


u it 


it 


7 


u 


" 4 " 5 


a 


a a 


u 


5 


u 


» 5 " 6 


(( 


it (( 


cc 


3 


a 







TREATMENT. 




5£ 


In the latter case — 












From 2 to 3 months after contagion 


in . 


2 instances 


" 3 " 4 " 


« 


« 


it 


6 


" 


" 4 " 5 " 


u 


u 


a 


5 


" 


» 5 " 6 " 


a 


a 


a 


5 


a 


" 6 " 7 " 


a 


a 


a 


6 


a 


" 7 " 8 " 


a 


a 


it 


2 


" 


« 8 u 12 « 


a 


a 


a 


5 


u 


" 12 " 18 " 


it 


a 


a 


3 


a 



I will again remind the reader that these dates have reference to 
the first development of the eruption only. The difference in the 
two tables shows the power possessed by mercury to delay the 
appearance of secondary symptoms. 

Mucous patches are exceedingly chronic and persistent, and are 
very prone to reappear; they are, indeed, the most frequent evi- 
dence of the renewed activity of the syphilitic diathesis. 

Treatment. — In addition to the general treatment by mercury 
which mucous patches require in consequence of the indication 
they afford of the existence of the syphilitic diathesis, certain local 
applications are advisable. In the case of condylomata, Eicord's 
favorite treatment, which consists in washing them twice a day with 
Labarraque's solution of chlorinated soda, then sprinkling them 
with calomel and separating the opposed surfaces by the interposi- 
tion of lint, is generally very successful, but it is sometimes neces- 
sary to destroy them with nitrate of silver, nitric acid, or the acid 
nitrate of mercury. 

Mr. Victor de Meric speaks highly of an ointment employed by 
several physicians of the German Hospital, London, consisting of 
two drachms of calomel, the same quantity of sulphate or oxide 
of zinc (it matters not which), and one ounce of lard. After a few 
applications, the excrescences become dry and horny, fall off and 
leave a raw surface which soon heals. When there is much in- 
flammation present, the application of poultices should precede 
this treatment. 1 

Mucous patches in the mouth should be touched with nitrate of 
silver or one of the stronger caustics, and various gargles may be 
employed which will be mentioned in a subsequent chapter. 



1 Lettsomian Lectures, p. 42. 



586 GUMMY TUMOES. 



CHAPTER X. 

GUMMY TUMORS. 

Feom the fact that gummy tumors are among the latest symp- 
toms of syphilis, they are described in most works on venereal in 
one of the closing chapters. I prefer to consider them thus early 
because they afford me an opportunity of speaking of a peculiar 
product of syphilis, a knowledge of which is essential to the proper 
understanding of the subsequent pages. Nor is this course incon- 
sistent with the general plan of this work, in which it has not been 
my purpose to treat of syphilitic affections exclusively in their 
chronological order, but in whatever connection I could hope to 
place them in the clearest light before the reader; and this object, 
I think, will be best accomplished by a description founded upon 
the seat of the disease, and embracing tertiary lesions — in which 
the gummata play so important a part — at the same time with 
secondary. This has already been done in the chapter upon syphi- 
litic affections of the skin, in which both the early and late syphi- 
lodermata have been included ; and the same topographical plan 
will be pursued in the remainder of the work. 

The term "gummata," or gummy tumors, is applied to one of 
the later manifestations of syphilis which usually appears at least 
several years after contagion and never within a period of six 
months, and consists of small tumors which are developed in the 
cellular tissue underlying the skin and mucous membranes, and 
which slowly progress to suppuration and ulceration. These 
tumors are the type of a class which includes others developed in 
the muscles, tendons, viscera, testicles, etc., but, when the name is 
used without a qualifying epithet, those of the cellular tissue are 
alone intended, although we also speak of " gummy tumors of the 
muscles," " of the tendons," " of the heart," " of the testicles" 
(syphilitic orchitis), etc.; all of which depend upon a deposit of 
the same material in the normal tissue of the organ. 



GUMMY TUMORS. 587 

Gummy tumors of the cellular tissue commence as hard lumps, 
freely movable upon the subjacent tissues- and beneath the skin, 
which is not altered in appearance. They are at first unattended 
by pain or inflammation, and occupy a long period, as, for instance, 
several months or a year, in attaining their full development. 
Sooner or later, however, they become somewhat tender on pres- 
sure, of a softer consistency, and adherent to the integument; 
suppuration commences at the centre and never in the surrounding 
cellular tissue; the skin covering them assumes a dark red or 
livid color, is thinned, ulcerates and gives exit to a small quantity 
of ichorous pus. The dissolution of the adventitious deposit 
which commenced at the centre of the tumor, advances towards 
the superficies, and gives rise to a deep and extensive ulceration 
overhung by an irregular border of skin which is thinned and 
undermined. The reparative process does not begin until the 
external layers which formed a kind of cyst about the tumor, 
have been cast off by suppuration ; and the subsequent cicatrix, 
depressed, at first of a violet and afterwards of a dull white color, 
has the appearance as if produced by a deep burn. 

Gummy tumors are rarely multiple ; but a number often appear 
in succession for a long period. They may occur upon all the 
external parts of the body, but are most frequent upon the ex- 
tremities, neck, and head. Their size varies from a small nut to a 
hen's egg. I have recently been treating one upon the arm just 
above the elbow-joint, which gave rise to an ulcer three-fourths of 
an inch in depth and from an inch and a half to two inches in 
diameter. When seated in the neighborhood of the bones, as upon 
the scalp or walls of the pharynx or palate, they may give rise to 
caries and necrosis. Gummy tumors are not unfrequently devel- 
oped in the cellular tissue beneath the dartos of the scrotum, 
where they have been mistaken for syphilitic orchitis, and have 
led to the mistaken notion that suppuration, which is really a very 
Tare termination of the latter affection, is of common occurrence. 1 
Ricord has given a fine illustration of gummy tumors in this 
situation (Iconographie, PL XXXVIIL). 

I shall repeatedly have occasion to_speak of gummy tumors in 
the remaining chapters of this work in connection with syphilitic 

1 Mr. Hamilton, of Dublin, in his Essay on Syphilis (quoted by Langston Parker, 
p. 219) has evidently committed this error. 



588 GUMMY TUMOES. 

affections of different regions ; as ; for instance, the sloughing ulcers 
of the fauces, syphilitic tubercles of the tongue, tumors of the 
muscles, tendons, etc. 

The microscopical appearances of gummy tumors are thus de- 
scribed by Lebert : "A thin section of the tumor is found to con- 
sist of loose fibrous tissue, made up of pale elastic fibres, inclosing 
in their large interspaces a homogeneous, granular substance, the 
elements of which are less adherent to each other than in deposits 
of true tubercle. These granulated cells or corpuscles do not ex- 
ceed in size m , 005 ; they are rounded and contain an irregularly 
granulated substance ; and some of the larger corpuscles attain the 
size of m , 0075, have pale and irregular walls, and appear to 
contain a rounded nucleus." l 

Eobin says that "these tumors are made up of rounded nuclei 
belonging to fibro-plastic cells, or cytoblastions ; of a finely gran- 
ular, semi-transparent and amorphous substance; and finally, of 
isolated fibres of cellular tissue, a small number of elastic fibres, 
and a few capillary bloodvessels." 

The anatomical elements of syphilitic tubercle are not peculiar 
to this disease, for they are found in the healthy tissues and also in 
tumors which have no connection with syphilis. This deposit, 
however, is remarkable from the extent to which it is found in 
syphilitic lesions. It has been detected in the bones and perios- 
teum ; in syphilitic tumors of the nerves, muscles, and tendons ; in 
the liver, heart, brain, lungs, and testicles ; its deposit in the submu- 
cous tissue precedes the sloughing ulcers of the pharynx and larynx ; 
it forms the tubercles which are observed in the skin, tongue, etc. ; 
and Yirchow asserts that it is present even in the indurated base 
of infecting chancres. The extent to which this deposit may be 
found has but recently attracted attention, and sufficient time has 
not yet elapsed to determine its exact limits. Yirchow's attempt 
to found a classification of syphilitic lesions into "passive and 
active," based upon the absence or presence of this deposit, must, I 
think, to say the least, be regarded as premature. 2 

The treatment of gummy tumors of the cellular tissue is almost 
wholly included in the internal administration of iodide of po- 
tassium, which certainly has a much greater power than mercury 

1 Note to M. Van Oordt, Des Tumeurs Gommeuses, These de Paris, 1859, p. 16. 

2 See p. 466. 



GUMMY TUMORS. 5S9 

in effecting the cure of the local disease ; although mercurials are 
generally required to prevent a relapse or the occurrence of other 
forms of syphilitic manifestations. 

Both Eicord and Yidal recommend what would appear to be a 
very questionable mode of practice, viz., the extirpation of the 
tumor with the knife before suppuration has taken place or the 
surrounding parts have become inflamed. These tumors should 
be opened as soon as fluctuation can be detected ; and the subse- 
quent ulcers, if inclined to spread, should be treated like other 
sores which assume a phagedenic character. 



590 SYPHILITIC AFFECTIONS OF MUCOUS MEMBKANES. 



CHAPTER XI. 

SYPHILITIC AFFECTIONS OF MUCOUS 
MEMBRANES. 

Attempts have been made by several authors, and especially by 
Babington, 1 Eicord, 1 and Baumes, 2 to establish a classification of 
syphilitic eruptions upon mucous membranes founded upon their 
initial lesion, as is the case with the syphilodermata. There is no 
doubt that the manifestations of syphilis upon these two regions 
exhibit a general correspondence, which, indeed, in the case of 
erythema and tubercles is almost perfect, and which may be 
traced between the superficial erosions of vesicles, the deep ulcers 
of the late form of ecthyma, and the eroding ulcers of tubercles 
upon the skin on the one hand, and the aphthas and excavated 
ulcerations of the mouth and fauces on the other. But the attempt 
to carry this analogy still farther has led to presumptions which, 
I think, are somewhat fanciful, as in the supposed identity of the 
grayish pellicle of mucous patches with the squamse of scaly 
eruptions upon the skin ; and it must in general be confessed 
that although points of resemblance are often apparent between 
syphilitic eruptions upon cutaneous and mucous surfaces (which 
are indeed but one continuous membrane), yet that the physical 
conditions in which the latter are placed — their constant moisture, 
exposure to friction, etc. — prevent as accurate a classification as 
we are able to establish in the former. In what I have to say of 
syphilitic eruptions upon mucous membranes, I shall take every 
occasion to point out any analogy which may exist between them 
and the syphilodermata, but shall avoid any attempt at a classifi- 
cation founded upon the supposed initial lesion, hoping thereby to 
avoid unnecessary subdivisions and to place the subject in a clearer 
light before the reader. 

1 Notes to Hunter on Venereal, p. 429 and 447. 
8 Traite des Maladies Veneriennes, ii. p. 443. 



ERYTHEMA — ULCERS. 591 

Erythema. — Erythema of the mucous membranes is identical, 
in the time of its appearance and in its general characters, with the 
same eruption upon the skin. Like the latter, it appears between 
six and eight weeks after contagion, when mercury has not been 
administered, and may probably affect any of the outlets of 
mucous canals, although it is most frequently seen upon the 
fauces, pituitary membrane, and genital organs, and in many in- 
stances doubtless fails to attract attention. Upon the fauces it 
presents an appearance of redness and congestion, either generally 
diffused over the surface or circumscribed in patches, is often 
attended by more or less oedema, and frequently terminates in the 
formation of mucous patches. 

I have in several instances observed erythema of the mucous 
membrane covering the glans penis and lining the prepuce, in- 
dependently of any eruption upon the external integument. In a 
case recently under my care, in which I was watching for the 
appearance of general symptoms after the cicatrization of a chancre 
of doubtful character, redness of the membrane lining the furrow 
at the base of the glans led to further examination, when I found 
a pustule upon the scalp and engorgement of two cervical ganglia, 
although there was no eruption upon the body. Eicord has de- 
scribed and figured 1 a case of erythema of the glans penis coexist- 
ing with roseola upon the trunk, in which the former eruption was 
arranged in circles of a bright-red color, inclosing sound portions 
of the mucous membrane, and closely resembling the roseola upon 
the body. 

Ulcers. — Ulcerations of mucous membranes may be divided 
into three varieties, viz : 1. Superficial erosions ; 2. Ulcers of 
limited extent and depth, commencing upon the surface and 
penetrating the whole thickness of the mucous membrane; and, 
3. Phagedenic ulcers, which commonly originate in tubercles or 
gummy tumors of the submucous cellular tissue, and which are 
exceedingly destructive in their character. It will be observed 
that in the first two varieties ulceration commences from without, 
and in the last from within the mucous membrane. 

1. The superficial form is a mere erosion or aphtha, which does 
not penetrate beneath the epithelium, and which arises in the 
following manner : The mucous membrane becomes congested in 

1 Iconographie, PI. XV. 



592 SYPHILITIC AFFECTIONS OF MUCOUS MEMBRANES. 

the part which, is to be occupied by the ulcer, and a slight effusion 
of serum takes place beneath the epidermis, which is soon com- 
pletely detached and exposes a superficial erosion, presenting a 
smooth and somewhat polished surface which is sometimes covered 
with a slight exudation at the centre but which does not assume 
the grayish pellicle peculiar to mucous patches. 

Syphilitic aphthae may appear upon the genital organs in both 
sexes, and also within the buccal and nasal cavities and upon the 
fauces. They are frequently seen of variable extent upon the sides 
and dorsum of the tongue, which, in the part affected, is deprived 
of its papillary layer, and presents a smooth polished surface in 
striking contrast with the furry coat around it. Eicord has given 
a good representation of syphilitic aphthae upon the side of the 
tongue in his Iconographie, PL XX. bis, Fig. 4. 

2. The second variety is an excavated ulcer, involving the whole 
thickness of the mucous membrane; its edges are abrupt and 
sharply cut ; its floor covered with a diphtheritic exudation of a 
dull grayish color, and its secretion purulent. These characters 
are nearly identical with those of the chancroid, and the ulcer in 
question has sometimes been called an amygdaline or secondary 
chancre. The soft chancre, however, is rarely, if ever, met with in 
the buccal cavity, and may always be recognized by its suscepti- 
bility of inoculation upon the person bearing it. Experimental 
inoculation cannot be employed to distinguish between a secon- 
dary ulcer and an infecting chancre, neither of which is auto- 
inoculable. 

The ulcer now under consideration is the analogue of the deep 
form of ecthyma, and belongs to a later stage of constitutional 
infection than the superficial erosion last described. It is almost 
always sluggish in its course, and, especially in cachectic subjects, 
exhibits a decided tendency to spread. Its most frequent seat is 
upon the tonsils, which may be entirely destroyed by the progress 
of the ulcer. The neighboring parts are more or less red and 
swollen, and deglutition is attended with difficulty and pain. This 
affection should be carefully distinguished from tertiary ulcerations 
of the throat, and the diagnosis may almost always be established 
if regard be paid to the time which has elapsed since contagion, 
the appearances of the parts affected and the concomitant symp- 
toms, whether belonging to the secondary or tertiary stage of 
syphilis. 



ULCEUS. 593 

3. The third variety of ulcerations of the mucous membranes is 
commonly due to the suppuration of syphilitic tubercle deposited 
in the submucous tissue. 1 The commencement of the attack may 
readily pass unnoticed, especially as mercurial treatment of the 
primary sore may have entirely prevented the appearance of 
secondary symptoms, and many years of uninterrupted health 
have led the patient to entertain hopes of security for the future. 

When involving, as it frequently does, the neighborhood of the 
fauces, the earliest symptoms consist of slight pain in deglutition, 
and indistinctness of speech; and if the throat be examined at 
this time, more or less swelling and redness are discovered con- 
fined to some one portion of the surface ; in most cases, however, 
the patient does not seek advice until suppuration has taken place 
and produced an ulcer. The sore thus formed is surrounded 
by an irregular border, is covered with a pseudo-membranous 
secretion of a yellowish-gray color, and constantly extends by a 
process of phagedenic ulceration, which is not limited even by the 
osseous tissues. 

The tubercular deposit may have taken place in the cellular or 
muscular tissues intervening between • the two mucous layers of 
the soft palate, in which case the ulcer opens a communication 
between the mouth and posterior nares and eats away the uvula ; 
or, again, the disease may originate in the walls of the pharynx, 
and, unless arrested by treatment, destroy the pillars of the fauces 
and tonsils, advance upwards to the posterior nares and involve 
the Eustachian tube and middle ear, or downwards and encroach 
upon the base of the tongue, oesophagus, epiglottis, and larynx. 
The breath is rendered intolerably fetid, speech and deglutition 
are seriously interfered with, and a portion of the food is regurgi- 
tated through the nares. Deafness may be induced in consequence 
of the ulceration involving the Eustachian tube, or the oedema 
surrounding the ulcer closing its orifice; or the osseous tissues 

1 Dr. Wilks, in speaking of these ulcers in the larynx, says : " In the larynx, the 
term ulceration has been employed ; but this is secondary to the deposition of an 
adventitious material in the submucous tissue, and by which indeed this form of 
disease is, I think, recognizable ; the walls of the tube are much thickened and 
indurated, apart from the ulceration which may be present on the mucous mem- 
brane : and in some cases the whole disease may consist in a mass of hard tissue, 
like a node or tumor, occupying the glottis and obstructing the passage." (Patho- 
logical Anatomy, p. 4l»3.) 
'66 



594 SYPHILITIC AFFECTIONS OF MUCOUS MEMBRANES. 

may be attacked, giving rise to caries and necrosis of the cervical 
vertebrae, bard palate, or maxillary bones. The general condition 
of the patient, which in most cases was enfeebled at the outset of 
the disease, becomes reduced to a very low ebb ; emaciation and 
hectic fever may set in and death ensue. In those cases which 
terminate favorably, the edges of the ulcer subside, its surface 
cleans off, healthy granulations spring up, and the ulceration finally 
heals leaving a white, indurated and tendinous cicatrix to mark its 
site. 1 

Dr. "Wilks says of the post-mortem appearances of syphilitic 
ulcerations of the mucous membranes : " When a syphilitic ulcera- 
tion is examined after death, it may generally, I think, be told, for 
the reason I named when speaking of the larynx, by the adventi- 
tious fibrous deposit or lymph which is formed in the tissue, and 
thus, besides the ulceration, you find the adjacent parts much thick- 
ened and indurated." 2 

Tubercles of the Tongue. — Syphilitic tubercles may also appear 
beneath the mucous membrane or in the substance of the tongue, 
and give rise to phagedenic ulcers occasioning the partial or almost 
total destruction of this organ. M. Lagneau has recently published 
an interesting essay on this affection, based upon an analysis of 
five cases observed by Eicord and Bouisson, and five others not 
previously reported. 3 It appears from this author's researches that 
syphilitic tumors of the tongue do not occur except at a late period 
of constitutional infection ; but that they are not necessarily accom- 
panied by general cachexia as asserted by some authors, since many 
patients appear to be in a state of perfect health. In some cases they 
affect the superficial and in others the deeper portions of the tongue, 
or, again, all the lingual muscles may be involved ; at the com- 
mencement of the disease the base of the tongue is most frequently 
attacked. The superficial forms correspond to tubercles of the 
integument and cellular tissue ; the deeper to the gummy tumors 
which are observed in the muscles and tendons of various parts of 
the body. 

Syphilitic tubercles of the tongue are sometimes isolated and at 

1 Representations of tertiary ulcerations of the throat may be found in Ricord's 
Iconographie, Pis. XXXIV. and XXXVII. 

2 Lectures on Pathological Anatomy, London, 1859, p. 258. 

3 Gaz. Hebdomadaire, 1859, Nos. 32, 33, 35. 



TUBERCLES OF THE TONGUE. 595 

other times multiple ; their size varies from a buckshot to a small 
nut ; they are generally globular but sometimes irregular in shape ; 
at first of a grayish but after suppuration has takeu place of a yellow 
color; at their commencement they are almost as hard as cartilage, 
but they gradually soften into a pasty consistency and finally open 
and give rise to ulcers varying in depth, oblong in form and sur- 
rounded by irregular and abrupt margins. 1 

The floor of the ulcers is of a grayish color, rarely covered by a 
diphtheritic secretion, and sometimes presents small patches of gan- 
grene ; the base is at first indurated, but gradually becomes soft ; 
the ulcer readily bleeds from contact with the teeth. The union of 
several ulcers may occasion the destruction of a considerable portion 
of the tongue, which remains very much deformed after cicatriza- 
tion has taken place. 

In many cases these tumors can only be recognized at their com- 
mencement by grasping the tongue between the fingers, to which 
the organ imparts a sensation as if filled with small nuts. At a 
later stage, it becomes swollen either partially or wholly, and hence 
is liable to be bitten by the teeth, and in some cases protrudes from 
the mouth. There is frequently a constant and copious flow of 
saliva, and sometimes difficulty and pain in swallowing, speaking, 
and even breathing. The submaxillary ganglia are very rarely 
affected, and this is a very important diagnostic sign between 
syphilitic tubercles and cancer of the tongue. Moreover, in the 
former affection there are usually several masses of induration oc- 
cupying by preference the dorsum and base of the tongue ; while in 
the latter there is only one which is most frequently seated upon 
the side of the organ. The absence or presence of lancinating pain 
and the effect of treatment will also aid in establishing the diag- 
nosis, which may in some cases be difficult, especially after ulcera- 
tion has taken place. 

Syphilitic tubercles may also affect the lips where they have been 
mistaken for epithelial cancer ; but the former are generally situ- 
ated at some distance from the margin, while cancer first appears 
upon the free border of the lips in the form of a wart or ulcer 
covered with a scab, and is, moreover, attended by lancinating 
pains. 

Kicord describes a case in which he found two syphilitic tu~ 

1 Iconographie, PI. XXXV., Figs. 1 and 2. 



596 SYPHILITIC AFFECTIONS OF MUCOUS MEMBEANES, 

bercles of the size of a pea in the substance of the glans penis, and 
states that he has met with others in the neck of the uterus. 1 

Tkeatment of Syphilitic Affections of the Mouth and 
Theoat. — The treatment of syphilitic affections of the mouth and 
throat resolves itself into constitutional and local. For an account 
of the former I must refer the reader to the chapter upon the treat- 
ment of general syphilis. Suffice it at present to say, that mucous 
patches, erythema, and the superficial forms of ulcers belong to the 
secondary stage of syphilis and require the use of mercurials in 
accordance with the directions given in the chapter referred to. 
Tubercles and sloughing ulcers, on the other hand, should be treated 
exclusively with iodide of potassium, a nourishing diet and tonics, 
at least until the local affection is relieved, and the general health, 
if previously impaired, is raised to the normal standard, when mer- 
curials may be employed as a prophylactic against farther trouble. 
The value of the potassio-tartrate of iron in large doses in all 
cases of sloughing ulcers should not be forgotten. The moist mer- 
curial vapor bath, so administered that the fumes may be inhaled, 
is deserving of high commendation in syphilitic affections of the 
fauces. 

In consequence of the great inconvenience, suffering, and even 
danger attending many of these affections of the mouth and throat, 
local treatment is of paramount importance. The cicatrization of 
mucous patches, and superficial ulcerations, whether situated upon 
the lips, internal surface of the cheeks, tongue, or fauces, should be 
promoted by the application of the solid crayon of nitrate of silver. 
When this is not successful, and in nearly all cases of the ash- 
colored, excavated ulcers upon the tonsils or uvula, the stronger 
caustics, as nitric acid or the acid nitrate of mercury, must be 
employed. In making these latter applications, great caution is 
required, lest the acid come in contact with the sound tissues, or its 
fumes be inhaled ; and these evils may be avoided by taking care 
that the probang or glass rod which is employed be not so wet as 
to permit the fluid to drop from it, and by allowing the fumes to 
pass off before the remedy is applied. 

The application of caustics should, however, be deferred in cases 
attended by severe inflammation and swelling of the fauces, which 

1 Icoiiographie ; remarks upon the case figured in PL XXXIV. 



TREATMENT. 597 

must first be subdued by saline cathartics, rest, mustard pediluvia, 
low diet, and sometimes by leeches at the angle of the jaw. I have 
found the most grateful topical application under these circum- 
stances to be a solution of tannin in glycerin (3j to the 3j, with the 
addition of extract of opium if the pain be severe), which may be 
applied with a camel's-hair brush two or three times a day. Best 
should be promoted by means of sedatives, of which Dover's pow- 
der is the best. 

So soon as the acute inflammation has subsided, various astringent 
and tonic gargles may be employed with benefit. One of the best 
that I am familiar with is the undiluted tincture of cimicifuga. It 
should be prepared from the fresh root, as otherwise the effect is 
much diminished. Washes and gargles containing Labarraque's 
solution, chlorate of potash, the bichloride of mercury, or the 
oxymel of the subacetate of copper also serve an excellent purpose. 



E:. Liquor, sodas chlorinatae 


3ij-3 iv - 


I£. Hydrarg. bichloridi gr. vj. 


Mellis 3j. 




Acidi hydroclilorici gtt. xij. 


Aquas §v. 




Syrupi gj. 


M. 




Aquas ^viij. 
M. 


R,. Potassas chlorat. 5j« 




R,. Oxymellis cupri subacetatis §ij. 


Infusi lini Oj. 




Aquas §vj. 


M. 




M. (Langston Parker.) 



Either of the above washes may be used three or four times in 
the twenty -four hours. In fetid and phagedenic ulcerations of the 
throat, the following is a valuable formula : — 

I£. Creasoti rr^x. 

Mellis t f j. 

Aquas §vij. 
M. 

In all syphilitic affections of the mouth and throat, the surgeon 
must insist upon the patient's abstaining from the use of tobacco, 
which is found in practice to be the most common cause of the 
persistency of these lesions and of their frequent return after re- 
moval. 

Tubercles beneath the mucous membrane of the soft palate or 
pharyngeal walls should be laid open with the knife as soon as 
suppuration can be detected, and if the resulting ulcers assume a 
sloughing character they should be touched with the stronger 
caustics. The compound tincture of iodine diluted with water (a 



598 SYPHILITIC AFFECTIONS OF MUCOUS MEMBRANES. 

drachm to six ounces) is a favorite gargle with Eicord after acute 
inflammation has subsided. 

Syphilitic Stricture of the (Esophagus. — In an able paper 
by Mr. James F. West, Surgeon to the Queen's Hospital, Birming- 
ham, which was published in the Duhlin Quarterly Journal of 
Medical Science for Feb. 1860, the probability, if not the absolute 
certainty, that stricture of the oesophagus may be due to constitu- 
tional syphilis was first established. 

The case upon which Mr. West's observations were chiefly 
founded was one of a girl aged 21, who had suffered for several 
years from well-marked syphilitic manifestations, such as eruptions 
upon the skin, ash-colored ulcerations of the fauces, rheumatic 
pains, and syphilitic cachexia, and who was admitted into Queen's 
Hospital, May 18, 1858, for stricture of the oesophagus. Treatment 
by means of tonics, iodide of potassium, and mercurials afforded 
only temporary relief, and she succumbed on Sept. 2, of the same 
year. The following appearances were found at the post-mortem 
examination : " The upper portion of the oesophagus for about four 
inches was much dilated; its mucous membrane thickened, and 
marked by spots having the appearance of recent cicatrices. At 
this distance from the upper end it was suddenly constricted, and 
terminated in a narrow canal which would barely admit a No. 4 
catheter. This constricted portion, which was about two inches 
and a half in length, was formed by the thickening of the mucous 
membrane, and by fibrous deposit in the form of bands and bridles, 
having very much the appearance of an old stricture of the urethra. 
Below this track the oesophagus continued perfectly healthy to its 
termination in the stomach. Both lungs contained tubercular 
deposit in different degrees of softening, with several small cavities 
in the upper lobe of each, one in the left apex being as large as a 
pigeon's egg. 11 

In reviewing this case Mr. West remarks : " We have no account 
of the swallowing of any caustic or irritating fluid, so that we can- 
not attribute the stricture to that cause. The presence of numerous 
recent cicatrices clearly indicated that ulcerations had existed in 
the walls of the oesophagus. The deposit in the submucous tissue 
was fibrous ; it was exactly similar in nature to that which is so 
well described by Dr. Wilks 1 as characteristic of syphilitic ulcera- 



Quoted upon p. 607 of the present work. 



STOMACH AND INTESTINES. 599 

tion ; and could not under any supposition be referred either to can- 
cerous or tubercular degeneration." 

Mr. West 1 has since reported another case in which the patho- 
logical appearances were very similar, and states that Mr. Langston 
Parker has recently met with a case of constitutional syphilis in 
private practice in which unmistakable stricture of the oesophagus 
existed. 

In reviewing this subject it appears extremely probable that Mr. 
"West is right in his conjecture as to the cause of the stricture in 
the cases which have come under his observation, since we may 
readily admit that syphilitic ulceration of the fauces may extend to 
the oesophagus or attack the latter as a primary affection ; and yet 
it is singular that this effect of syphilis has attracted so little atten- 
tion from previous observers, and to the names of those authors who 
are quoted by Mr. West as silent upon the subject, I will add that 
of Yvaren, whose work on the Metamorphoses de la Syphilis in- 
cludes nearly all the obscure forms of syphilitic disease, so far as 
they are known. Follin, 2 however, was of the opinion that some of 
the reported cases of stricture of the oesophagus might be attributed 
to syphilis, and Yirchow has met with contraction of the upper 
portion of this tube in the post-mortem examination of a syphilitic 
subject. 3 

In the first case reported by Mr. West, iodide of potassium and 
mercurial fumigations were used without benefit, while in the second 
case the former remedy is said to have given temporary relief. It 
is probable, however, that the stricture is due to contraction of the 
cicatrix, and not to the ulcer itself, and hence that it is not amenable 
to specific remedies and can only be palliated by mechanical dila- 
tation. 

Syphilitic Affections of the Stomach and Intestines. — 
Functional disturbance of the digestive organs is not an uncommon 
effect of the contamination of the blood by the syphilitic virus, as 
shown by the loss of appetite or the occasional inordinate desire 
for food, and the nausea and vomiting, which sometimes accompany 
the appearance of early secondary manifestations. 4 The general 
cachexia belonging to the later stage of syphilis may also be at- 

1 Dublin Quart. Journal of Med. Sci. 

2 Des Retrecissements de l'G3sophage, Paris, 1853, p. 30. 

3 Syphilis Constitutionnelle, p. 88. 4 See p. 547. 



600 SYPHILITIC AFFECTIONS OF MUCOUS MEMBRANES. 

tended by intestinal derangement. The evidence is much less con- 
clusive that syphilis ever gives rise to organic changes in the 
stomach and intestines, similar to those that are met with in the 
mouth, rectum, and other outlets of mucous passages. 

Yvaren was able to collect but four cases in which there was 
any appearance of direct connection as cause and effect between 
syphilis and diseases of the parts in question. 

The first was a case of dysentery reported by Boyle, 1 the details of 
which are too imperfect to justify a conclusion as to its nature, but which 
was probably simple ulceration of the rectum. 

The second, reported by Baumes, 3 was a case of gastralgia, hepatalgia, 
and hypochondria, of eight years' duration. The only antecedent syphi- 
litic symptoms were a chancre and non-suppurating bubo, which were 
treated by mercurials. The patient was sent to some mineral spring, 
when a syphilitic serpiginous eruption appeared and the intestinal symp- 
toms ceased. 

The third case, reported by Andral, 3 was one of a woman, aged 29, who 
had daily attacks of vomiting which prevented her retaining food upon 
the stomach, and tenderness over the epigastrium, but without any evi- 
dence of the existence of a tumor or disease of the liver. These symptoms 
were uncontrollable by the usual remedies employed in such cases, and 
organic disease of the stomach was suspected ; but the appearance of a 
syphilitic ulcer upon the fauces led to the administration of mercurials 
under which she obtained complete relief. Her antecedents had been 
of a suspicious character. 

In the fourth case reported by the same author, 4 symptoms of chronic 
gastritis and phthisis pulmonaris disappeared under the use of mercurial 
inunction in a person undoubtedly affected with constitutional syphilis. 

Cullerier 5 has also endeavored, with very questionable success, to 
establish the existence of tertiary enteritis, dependent upon gum- 
mata of the submucous cellular tissue of the intestines, in infants 
affected with hereditary syphilis ; and he believes that this is the 
cause of the larger proportion of deaths in infants born of syphilitic 
parents. Again, Pillon 6 has reported a supposed case of secondary 

1 Sauvages, Medecine Method., viii. p. 180. 

2 Precis des Maladies Veneriennes, t. i. p. 372. 

3 Clinique M6dicale, t. iv. p. 122. 4 Op. cit., t. iv. p. 122. 

5 L'Union Medicale, 1854. No. 137. Virchow says that the affection described 
by Cullerier is only simple ulceration of the intestinal follicles. (Syphilis Consii- 
tutionnelle, p. 162.) 

6 Gaz. des Hop., 1857, No. 66. 



SYPHILITIC STEICTUEE OF THE RECTUM. 601 

enteritis in an adult coinciding with an eruption of roseola upon 
the integument. 

None of these cases, however, can be regarded as entirely con- 
clusive, although they are sufficient to induce the practitioner, 
when ordinary remedies fail to afford relief in obstinate affections 
of the intestinal canal occurring in syphilitic subjects, to make a 
cautious trial of mercurials. 

Syphilitic Stricture of the Eectum. — Eectal stricture is 
sometimes of undoubted venereal origin ; although, as shown by M. 
Glosselin, its predominance in the female sex, its existence in cases 
free from syphilitic taint, the difference in the pathological changes 
from those usually produced by syphilis, and the inefficacy of 
specific remedies, prove that it is not due to infection of the consti- 
tution with the syphilitic virus ; and that hence the name "syphilitic 
stricture" is not, strictly speaking, correct. The exact mechanism 
of its production is somewhat obscure. Gosselin, who has especi- 
ally investigated the subject in an admirable paper in the Archives 
Generahs de Meclecine, 1 attributes it to a peculiar modification in 
the vitality of tissues bathed by the chancrous virus, the same which 
gives rise to hypertrophy of the prepuce and labia in men and 
women affected with primary sores, and to simple vegetations in the 
subjects of gonorrhoea. Still it is very questionable whether there 
is anything so "peculiar" in this effect of the chancrous virus that it 
may not be produced by the secretion of gonorrhoea or any irritant 
of a simple character; but however this may be, it is sufficient for 
our present purpose to know that venereal stricture of the rec- 
tum is due to the extension of inflammation from the anus and 
perineum, and is more common in women because these parts, from 
their anatomical position, are more exposed than in men to contact 
with irritant discharges from the genital organs. I propose briefly 
to state the symptoms of this affection as deduced from twelve cases 
observed by M. Gosselin, and the pathological changes found in 
three post-mortem examinations by the same surgeon. 

In several instances, the patients were not aware of the existence 
of a stricture, and simply complained of a frequent desire to go to 
stool, which was followed by a discharge of pus and sanguinolent 
mucus. Constipation, and difficult and painful defecation were 

1 Dec. 1854. 



602 SYPHILITIC AFFECTIONS OF MUCOUS MEMBRANES. 

present in but a few cases; the majority, especially when the 
disease was of long standing, suffered from habitual diarrhoea. An 
important symptom was the quantity of pus which was discharged 
from the rectum, either with or without fecal matter at stool, 
or involuntarily during the day. In addition, most of the patients 
lost flesh and strength, and suffered from various dyspeptic symp- 
toms. In nearly all, hypertrophied and prominent folds of the 
integument were found upon the margin of the anus, which were 
attributed by Gosselin to the same chronic inflammation which 
produced the stricture, and the contraction of the gut was invaria- 
bly situated at a short distance from the anus. 

In describing the post-mortem appearances, Gosselin lays con- 
siderable stress upon the anatomical division of the rectum into 
three portions, viz : the inferior portion, measuring about an inch 
and a half in length and corresponding to the external and internal 
sphincter ; the middle or dilated portion ; and the superior portion, 
which is narrower than the preceding, but is not separated from it 
by any well defined line of demarcation. Venereal stricture is 
situated at the juncture of the lower and middle portions, encroach- 
ing somewhat upon the latter ; or, in other words, is about an inch 
and a half or two inches from the margin of the anus, and does not 
appear to vary its position like strictures dependent upon other 
causes. 

The stricture is composed of an indurated and inextensible ad- 
ventitious deposit in the substance of the mucous membrane and in 
the submucous cellular tissue. It is never impermeable, nor so 
contracted as entirely to prevent the exit of fecal matter. The 
muscular tissue surrounding the contracted portion is somewhat 
hypertrophied. There is no evidence of any deposit similar to 
that found in gummy tumors. 

The lining membrane of the middle or dilated portion of the 
rectum above the stricture is denuded of its epithelium and glan- 
dular layer, giving rise to an extensive and continuous erosion for 
about four or five inches above the contraction, and the muscular 
tissue surrounding this portion is hypertrophied. This ulcerated 
surface is the chief source from which is derived the pus that is 
mingled with the stools and flows away involuntarily. Gosselin 
believes that so extended an erosion is peculiar to this class of 
strictures. 

In two of Gosselin's cases there could be little doubt of the vene- 



AFFECTIONS OF THE NASAL PASSAGES. 603 

real origin of the stricture, which was developed under the obser- 
vation of the surgeon while the patients were under treatment for 
obstinate chancres of the anus, one of which arose from the inocu- 
lation of matter proceeding from a chancre upon the vulva. The 
remaining cases were first seen after the stricture had formed, but 
in nearly all traces of the previous existence of primary sores 
were found. Gosselin is unwilling to attribute this affection to 
unnatural practices, nor has he been able to trace its origin to 
gonorrhoea of the rectum, which is, moreover, a very rare disease. 

Mercurials and iodide of potassium are found to have no effect 
whatever in relieving venereal stricture of the rectum. At the 
outset of the disease, dilatation either alone or combined with inci- 
sions may effect a cure; at a later period, they are, in most cases, 
only palliative. 

The twelve patients, upon whom these observations were founded, 
were all inmates of the Lour cine Hospital of Paris, in the year 1854. 
Two of them died in 1857 of pulmonary phthisis, and the post- 
mortem appearances did not materially differ from those in the 
three cases above described. A third, who had been kept under 
observation, was still maintained in a tolerable state of health by 
repeated dilatation and incision of the stricture and the adminis- 
tration of tonics. 1 

Two cases in confirmation of those of M. Gosselin have been 
reported, one by Mr. Holmes Coote, 2 and the other before the Ana- 
tomical Society of Paris. 3 

Syphilitic Affections of the Nasal Passages. — In the order 
of frequency of syphilitic manifestations, the nasal passages proba- 
bly come next to the buccal cavity, although the former are less 
exposed than the latter to observation, and, in many instances, 
their lesions consequently pass unnoticed. The pituitary mem- 
brane may be the seat of erythema, mucous patches and super- 
ficial ulcerations, which obstruct the nasal passages and give rise 
to a muco-purulent secretion and other symptoms resembling those 
of an ordinary catarrh, from which they differ in their greater 
persistency, and in their disappearance upon the administration of 
mercurials. Sometimes an ulcer can be seen just within the nasal 

1 Gaz. des Hop., Aug. 22, 1857. 

2 Med. Times and Gaz.. Jan. 27, 1855. 

3 Bulletin de la Soc. Anat. de Paris, 2d serie, t. iv., 1859, p. 100. 



604 SYPHILITIC AFFECTIONS OF MUCOUS MEMBRANES. 

orifice, surrounded by a swollen condition of the mucous mem- 
brane, and rendering the alae nasi tender upon pressure ; and plugs 
of inspissated mucus, mixed with blood and pus, are from time to 
time discharged from the deeper recesses of the organ. 

In a more advanced stage of the syphilitic diathesis, ulcers of 
a deeper description appear, which originate in tubercles devel- 
oped beneath the mucous membrane and gradually involve the 
cartilaginous and osseous textures; or the latter structures may 
be first attacked and the pituitary membrane become implicated 
secondarily. Dryness and obstruction of the nasal passages are 
the first symptoms complained of by the patient, but suppuration 
soon takes place, giving rise to an exceedingly fetid discharge of 
bloody pus and mucus, hard and dark-colored scabs, and fragments 
of necrosed bone ; the voice assumes a nasal sound ; the sense of 
smell may be lost; the patient breathes chiefly if not entirely 
through the habitually open mouth; the disease is exceedingly 
persistent, and finally leaves the nose flattened, or its bridge sunken 
from the partial destruction of its osseous and cartilaginous support. 
The remaining portions of the ossa nasi become thickened and 
eburnated, and are often separated superiorly so as to form a longi- 
tudinal furrow running along the dorsum of the nose. According 
to Yirchow, 1 this tendency to eburnation and thickening of the 
osseous tissue is not confined to the part first affected, but may 
extend to the bones composing the base of the skull. 

The earlier syphilitic affections of the nasal passages readily 
yield to the internal administration of mercurials, and rarely re- 
quire topical applications. In tertiary affections of the same organ, 
iodide of potassium, preparations of iron, the mineral acids, cod- 
liver oil, and other tonics must frequently be employed either 
alternately or in combination, and for a long period, in order to 
afford permanent relief to the disgusting and distressing symptoms. 
The most efficacious local treatment consists in mercurial fumiga- 
tions, which may be administered by means of the ordinary mercu- 
rial vapor bath, provided the general health of the patient be not 
too much reduced ; but a more convenient method is to evaporate 
a sufficient quantity of calomel, the bisulphuret or binoxide of mer- 
cury from a metallic plate heated over a spirit lamp, directing the 
fumes into the nostrils by means of a tunnel of paper or other 

1 La Syphilis Constitutionnelle, p. 64. 



SYPHILITIC APHONIA. 605 

convenient material. Injections of black wash, diluted chlorinated 
soda (one part to twelve or twenty of water), and weak solutions of 
nitrate of silver or chloride of zinc may also be of service. 

Syphilitic Affections of the Lakynx and Trachea. — The 
effects of syphilis upon the air-passages are chiefly confined to a 
late period of constitutional infection, and consist in ulceration of 
the mucous membrane and suppurative inflammation of the carti- 
lages. 

Syphilitic Aphonia. — Diday has described a singular affection of 
the larynx, independent of any appreciable lesion and accompanying 
early secondary manifestations, to which he has given the name of 
syphilitic aphonia. Its symptoms are of such a peculiar character, 
that it is not commonly noticed except in public singers, since the 
pronunciation is clear and distinct so long as a conversational tone 
is maintained, but as soon as the patient attempts to sound the 
higher notes of the musical scale, his voice fails him and he can 
scarcely emit an audible sound. This diminution in the compass 
and flexibility of the voice is the only indication of the disease. 
There are no symptoms of coryza, angina, or bronchitis, no cough, 
dyspnoea, pain, or difficulty in swallowing, nor general febrile ex- 
citement. Diday states that he has met with twenty cases of this 
affection, all of which occurred at an early period after the develop- 
ment of the infecting chancre ; and in five, of which he possesses 
accurate notes, the average interval was four months. The pathol- 
ogy of the affection is obscure. It is evident that it cannot be 
attributed to the sloughing form of ulceration which is known to 
affect the mucous membrane of the larynx in the later stages of 
syphilis. A more probable cause might appear to be the presence 
of mucous patches, but these lesions are rarely met with posterior 
to the fauces, and they would be attended with some degree of pain 
or uncomfortable sensations in the region of the larynx. Diday 
suggests that it may be due to paralysis of those muscles which 
govern the power of vibration in the borders of the rima glottidis. 
He admits, however, that this explanation is a mere supposition, 
which he adopts for the want of a better. I must confess that if 
Diday's cases had been reported by one less known as an accurate 
observer, I should be inclined to attribute them to laryngeal catarrh, 
the symptoms of which had not been recognized ; no such suspicion, 
however, is admissible under the circumstances, but I think that 



606 SYPHILITIC AFFECTIONS OF MUCOUS MEMBEANES. 

the pathology of the affection must be determined by future ob- 
servation. 

Syphilitic aphonia generally begins to improve on the second or 
third day after commencing mercurial treatment, and disappears 
in the course of a week. 1 

Syphilitic laryngitis, unlike the affection just mentioned, is always 
a late symptom of constitutional infection, occurring many months 
and generally many years after contagion. It is, in most cases, 
accompanied by tertiary manifestations, and even when isolated has 
always been preceded by other syphilitic symptoms, and frequently 
by sloughing ulcers of the fauces. 

This disease may consist in an ulceration of the mucous mem- 
brane, or in inflammation of the perichondrium surrounding the 
laryngeal cartilages. In the former case, it may have extended 
from an ulcer of the pharynx, or have originated in the larynx ; and 
it often involves the internal surface of the epiglottis, and the greater 
portion of the lining membrane of the laryngeal cavity. According 
to Virchow 2 it is always accompanied by inflammation of the neigh- 
boring perichondrium. The latter affection, however, may exist alone 
without ulceration of the mucous membrane, and an abscess form 
within the perichondrium denuding and destroying the cartilage, 
as is observed between the periosteum and bone in syphilitic peri- 
ostitis. The greater portion of the cartilage may become necrosed 
and separated in the form of a sequestrum, as in a case figured by 
Eicord. 3 The mucous membrane, even when not ulcerated, is usu- 
ally more or less oedematous. The existence of an abscess or in- 
flammatory deposit without the laryngeal cavity explains the 
enlargement of the throat which is sometimes visible externally, 
and the prominence of which is increased by the emaciation of the 
patient. 

At the commencement of the disease, the voice is husky, and 
respiration difficult ; slight pain is felt in the region of the larynx ; 
and the patient hawks up a small quantity of purulent matter 
mixed with blood, and sometimes containing small sloughs ; at a 
later stage, the voice is entirely lost or can be heard only in a 
whisper ; the larynx may be seen on external examination to be 
increased in size; the patient becomes very much emaciated, and 

1 Gaz. Med. de Lyon, No. 2, 1860. 

1 La Syphilis Constitutionnelle, p. 149. 

3 Iconographie, PI. XXX. 



SYPHILITIC LARYNGITIS. 607 

death may ensue from exhaustion or asphyxia. These symptoms 
do not materially differ from those of laryngeal phthisis, and the 
differential diagnosis may in some cases be attended with difficulty. 
The latter disease, however, is always accompanied by a deposit of 
tubercles in the lungs, and auscultation will therefore enable us to 
decide as to the nature of the affection, even when this is not evi- 
dent from the history of the case and the concomitant symptoms. 

The post-mortem appearances of syphilitic disease of the larynx 
and air-passages are thus described by Dr. Wilks : " In the tuber- 
culous disease of these organs, apart from the small amount of 
adventitious scrofulous deposit, the affection is characterized by the 
extensive ulceration, whereas, in the syphilitic form the peculiarity 
is the thickening and induration owing to a formation of fibrous 
tissue. The difficulty is in distinguishing between a syphilitic and 
a simple inflammatory form of disease ; but I believe the majority 
of cases of chronic laryngitis which we meet with are syphilitic, 
and the more likely is this to be the case when there is a large 
amount of fibrous deposit present. The disposition in constitu- 
tional syphilis is to the production of lymph, which may subse- 
quently become a tough fibrous tissue ; this you see in periosteal 
nodes, as well as in the same formations in other parts ; and thus 
in the larynx you may find sometimes, perhaps, nothing more than 
a mass of fibrous tissue developed in the glottis, and almost closing 
it ; in other cases you find, with this extreme thickening, also the 
epiglottis thickened and hardened ; or this condition may extend 
down the larynx as far as the trachea ; or the whole organ may be 
indurated throughout, and even sometimes the cellular tissue ex- 
ternally with the adjacent small lymphatic glands all matted to- 
gether, and implicated in the process. With this induration there 
is generally more or less destruction of the parts, and in most 
cases, no doubt, the ulcerative process has accompanied the indura- 
tion and contraction : and thus the inner surface has either lost its 
mucous membrane, or presents a cicatriform appearance. Some- 
times, if the ulceration is considerable, the whole of the inner 
surface of the larynx presents a shaggy or flocculent aspect, and 
occasionally the ulceration is continuous over the glottis, with an 
ulcer of the pharynx ; in such a case the question may arise as to 
the original site of the disease ; but, as both these parts may be in- 
dependently affected, it is possible that the disease in both has pro- 
gressed simultaneously. Other parts of the air-passages may be 



608 SYPHILITIC AFFECTIONS OF MUCOUS MEMBRANES. 

affected as well as the larynx, as you see in the specimen I now 
show you, where the lower part of the trachea is very much thick- 
ened, and the surface ulcerated ; and in the preparation I just now 
showed you, of contracted bronchus arising from an ulcer, the 
nature of the disease was clear, in the fact of the patient dying of 
syphilitic laryngitis: the contracted trachea also had the same 
origin. As I before mentioned, in some of these cases of ulcera- 
tion of the trachea the rings are laid bare, as you will see in these 
specimens ; and which sometimes become detached during life, if 
the patient recovers." * 

Syphilitic ulceration of the trachea, which is described by Dr. 
Wilks from preparations in Guy's Hospital Museum, has been 
noticed in a number of reported cases, in some of which the affec- 
tion was confined to the trachea and in others implicated also the 
larynx. Thus Virchow 2 cites the case of Marguerite RudloffJ who 
died of stricture of the larynx following syphilitic ulceration, and 
in whom cicatrices were found in the trachea and bronchia with 
stricture of the latter. 

It is an interesting fact that stricture of the air-passages conse- 
quent upon the cicatrization of a syphilitic ulcer may cause death 
from dyspnoea, so that specific remedies may in reality hasten a 
fatal termination just so far as they exert a beneficial influence 
upon the local disease. Two interesting cases of this description 
are given in the Annuaire de la Syphilis (annee 1858, p. 324). 

In the first, reported by Moissenet, the stricture was situated just above 
the bifurcation of the trachea. The lining membrane at this point pre- 
sented a honeycomb appearance, and the cartilages were more or less 
changed in their structure and destroyed ; indeed, four of the rings had 
entirely disappeared and were replaced by flexible tissue; hence, in addi- 
tion to the diminution in ihe calibre of the tube, its walls collapsed at 
each act of inspiration and added to the difficulty in the ingress of the 
air. The patient had been taking mercurials and iodide of potassium 
which only aggravated her symptoms. Tracheotomy was performed 
without benefit, since the larynx was unaffected and the obstruction was 
below the artificial opening. Death was caused by asphyxia. 

The following is a summary of the second case reported by M. 
Demarquay : — 



Pathological Anatomy, p. 204. 

La Syphilis Constitutionnelle, p. 151. 



SYPHILITIC LAKYNGITIS. 609 

The patient, aged 36, entered a maison de sante, Oct. 25, 1858, with all 
the symptoms of oedema of the glottis. He seemed to be threatened 
with suffocation ; his respiration was noisy and painful ; he had had a 
cough for two months with slight expectoration ; his sputa resembled 
those of laryngeal phthisis; and he had lost much flesh. For a fortnight 
his symptoms had been very intense. The lungs were found to be sound; 
and as the patient had had chancres twelve years before, followed six 
years afterwards by ulceration and perforation of the soft palate, iodide 
of potassium was ordered. Under this treatment he continued to improve 
for a month; but on Nov. 25th he was suddenly seized with such extreme 
dyspnoea that M. Demarquay thought it best to perform tracheotomy. 
The operation was of no benefit and death soon ensued. 

At the autopsy, the larynx was found to be perfectly healthy, with the 
exception of a small cicatrix between the two arytenoid cartilages; but 
the trachea was found to be abruptly contracted opposite its eleventh 
ring, at which point its circumference measured only 28 millimetres. This 
stricture involved the left side of the trachea and was formed of cicatricial 
tissue in which six rings of the tube were twisted on themselves and 
fractured. Below the stricture the bronchia were dilated, and their 
longitudinal muscular fibres hypertrophied. The lungs were healthy, and 
free from tubercles. 1 

The bronchia may also be the seat of syphilitic ulceration and 
consequent stricture. 

In the case of Marguerite Kudloff, reported by Yirchow, " the right 
bronchus was contracted at its bifurcation and above that point ; a 
section of it presented the form of a triangle ; its diameter measured 
a quarter of an inch, while that of the left bronchus measured half an 
inch. The left bronchus was contracted to a still greater extent near 
its bifurcation, but only for the distance of a quarter of an inch, and 
was adherent at this point to the normal oesophagus through the inter- 
vention of a thick and tendinous mass of tissue. The right bronchus 
was the seat of thickening and contraction which extended for a short 
distance into its branches, which farther on were reddened upon their 
internal surface and dilated. Several larger dilatations of the bronchia 
were found in the inferior lobe of the lung which was otherwise healthy ; 
and at these points the pulmonary tubes were filled with mucus and sur- 
rounded by condensed tissue which extended as far as the pleura." 

Yirchow concludes from this and another case of which he gives 
an analysis, that " we must admit the existence of syphilitic ulcera- 

1 Bulletin de la Soc. Anat. de Paris, 2e serie, t. ii. p. 484. 

39 



610 SYPHILITIC AFFECTIONS OF MUCOUS MEMBRANES. 

tion and stricture of the bronchia similar to the same lesions of the 
larynx, and must also concede that syphilitic bronchitis may give 
rise to chronic pneumonia, in the same manner as laryngeal ulcera- 
tions cause extensive induration of the cellular tissue of the neck. 
I have often seen in constitutional syphilis, limited star-shaped 
cicatrices of the pleura and pleurisies, in consequence of the above 
mentioned changes." 1 

Treatment. — The prognosis in syphilitic ulcerations of the air- 
passages is exceedingly unfavorable. The iodide of potassium, 
mercurials, nourishing diet and tonics may, in some cases, afford 
relief, while in others they prove inefficacious, or, in a few in- 
stances, as already remarked, may hasten a fatal termination by 
inducing cicatrization of the ulcer and consequent contraction and 
stricture. Carmichael believed that the ulcerative process was 
maintained by the transit of the air, and that the best method of 
cure was the early performance of tracheotomy. These views have 
not, however, been confirmed by recent surgeons, who resort to 
this operation only in cases of impending suffocation, and even then, 
since the stricture may be seated below the artificial opening, if 
for no other reason, the prospect of affording relief is very dubious. 

1 Op. cit., p. 154. 



SYPHILITIC AFFECTIONS OF THE EYES. 611 



CHAPTER XII. 

SYPHILITIC AFFECTIONS OF THE EYES. 

A large number of tissues enter into the composition of the 
orbit and its contents, and syphilitic affections of this region are 
correspondingly numerous ; but a minute description of all of them 
would be inconsistent with the limits of this work ; and I shall 
therefore merely allude to several of them and dwell chiefly upon 
those which are the most common and most likely to fall under 
the care of the general practitioner. 

Affections of the Bones of the Orbit. — Syphilitic nodes 
may be met with upon either of the four walls of the orbit. They 
are most frequent near the anterior opening of the socket, but may 
occur at a greater or less depth within its cavity and cause protru- 
sion of the eyeball and loss of vision consequent upon stretching 
of the optic nerve. The following cases are reported by Mr. 
Poland:— 1 

Case 1. John M , set, 41, a large, bony, well-developed man, be- 
came an out-patient at Moorfields, suffering from an extensive swelling of 
the bone at the upper part of the orbit, encroaching upon the eyeball so 
as to displace it downwards and forwards. The history of the case, as 
well as the present marks of old mischief, at once indicated the nature of 
the growth. 

From his statement, it appeared that about ten years ago he had un- 
deniable syphilitic inoculation ; hardened chancre and a non-suppurating 
bubo, followed by secondary symptoms of a rather protracted form. He 
underwent mercurial treatment, both internally and by ointment, and with 
benefit ; ultimately he became free from all symptoms, and since that time 
at intervals he has had occasional attacks of rheumatism, which have been 
relieved by iodide of potassium, and on more than one occasion he has 

1 On Protrusion of the Eyeball, Ophthalmic Hospital Reports, vol. ii. p. 223. 



612 SYPHILITIC AFFECTIONS OF THE EYES. 

had nodes on the tibia, which were relieved by blisters. The present 
swelling on the frontal bone had been in existence for nearly six weeks, 
and, within the last few days, had increased most rapidly in size ; it was 
perfectly firm and hard, but very tender and painful, and seemed to extend 
towards the orbit, instead of taking the usual course over the forehead, 
and had already encroached upon the eyeball, slightly displacing it down- 
wards and forwards. There were no cerebral symptoms whatever. 

The man was ordered to take three grains of the iodide of potassium 
three times a day, and to rub an ointment of the same on the swelling 
morning and night. By persevering with this treatment for three months 
the swelling entirely disappeared. 

Case 2. The second case was that of a woman nearly six feet in height 
and of immense bony development, who came under Mr. Poland's care at 
Moorfields, having a large node growing from the inner wall of the orbit ; 
it was perfectly solid to the touch, but pushed the eye outwards and 
forwards, and had caused tension of the optic nerve, so that there was 
loss of sight, dilated fixed pupil, and perfect immobility of the eye. She 
soon afterwards had severe cerebral symptoms, and died suddenly in a 
comatose condition. There was no examination of the body. 

I have never met with exophthalmos dependent upon this cause 
during five years' connection with the N". Y. Eye Infirmary. 

The bones of the orbit, and most frequently the frontal bone, 
may be the seat of caries, originating in syphilis and occasioning 
abscess and sinuses of the lids. 

Affections of the Lachrymal Passages.— Syphilis not un- 
frequently gives rise to changes in the lachrymal passages, causing 
obstruction to the flow of tears, epiphora and lachrymal abscess 
and fistula. Since these passages are not exposed to direct observa- 
tion, the exact nature of the changes in their walls is not always 
apparent. In a few instances, the disease appears to be confined 
to the mucous membrane and submucous tissue, and to consist in 
catarrhal inflammation, consequent oedema, and ulceration ; in the 
majority of cases, however, it commences in the bony wall or peri- 
osteum, and the mucous membrane is affected secondarily ; changes 
which correspond to those met with in other mucous membranes 
contiguous to bony tissue. The character of the coexistent syphi- 
litic symptoms may afford some idea of the changes in the tear 
passages, which, however, can only be accurately determined by 
direct exploration. 



AFFECTIONS OF THE LACHKYMAL PASSAGES. 613 

The symptoms are sufficiently obvious. The tears meeting with 
obstruction to their transit through the lachrymal passages, collect 
upon the conjunctival surface ; if profuse, they flow over upon the 
cheek, especially when the patient is exposed to the wind, and the 
eye is evidently more moist than its fellow, whence the name "watery 
eye" applied to this disease. Soon, pressure over the lachrymal 
sac causes a reflux into the eye of the lachrymal secretion mixed 
with more or less purulent matter, or the same result takes place 
spontaneously; the conjunctiva, especially that of the lower lid 
and inferior portion of the globe, is maintained in a constant state 
of irritation and inflammation, and the puncta are abnormally red, 
swollen, and prominent. In extreme cases an abscess forms in the 
lachrymal sac or neighboring cellular tissue, opens and gives rise 
to one or more fistulas. 

Much may be done for the relief and permanent removal of ob- 
structions of the lachrymal passages by the persevering and long 
continued use of specific remedies. The bichloride of mercury and 
iodide of potassium were for many years exclusively employed 
with very satisfactory results at the New York Eye Infirmary 
where this affection is very common. Many cases, however, refuse 
to yield to internal remedies alone, and in all a cure may be ex- 
pedited by a resort to the improved local treatment for which 
ophthalmic surgery is so largely indebted to Mr. Bowman of the 
Moorfields Ophthalmic Hospital. 1 

Mr. Bowman's treatment consists in slitting up the canaliculi as 
far as the caruncle, and afterwards dilating the passage into the 
nose by means of graduated probes as we would a stricture of the 
urethra. The first part of the above procedure is often sufficient 
to afford great relief to the patient by opening a free communication 
between the conjunctiva and sac, and by preventing collections of 
matter in the latter or facilitating their evacuation. One or both 
canaliculi having been slit up, an opportunity is afforded to explore 
the nasal passages with a full-sized probe (about one-twentieth of 
an inch in diameter), and to ascertain the nature of the obstruction. 
If this be due to swelling of the mucous and submucous tissues 
alone, the passage of a probe repeated every two or three days for 

1 See Mr. Bowman's papers in the Medical and Chirurgical Transactions, 1851, 
and in the Ophthalmic Hospital Reports, for Oct. 1857 ; also Remarks on Diseases 
of the Lachrymal Passages by the author in the Report of the N. Y. Eye Infirmary, 
N. Y. Journal of Med., July, 1859. 



614 SYPHILITIC AFFECTIONS OF THE EYES. 

a few weeks, and retained on each occasion for about half an hour, 
will in most cases suffice to re-establish the patency of the canal ; 
but when denuded bone can be felt, showing that the disease is 
seated in the periosteal or osseous tissues, Mr. Bowman's method 
will rarely prove successful, and it becomes necessary either to 
resort to obliteration of the sac and canaliculi (which should always 
be included) by the actual cautery, or to wait for the slow elimina- 
tion of the necrosed portions of bone under the internal adminis- 
tration of iodide of potassium. The old-fashioned style is rapidly 
going into disuse and has already been entirely abandoned at the 
Moorfields and New York Eye Infirmary. The danger and incon- 
venience attending its employment far more than counterbalance 
any benefit that can be derived from it. 

Syphilitic Affections of the Eyelids. — These may be pri- 
mary or secondary. All chancres that have been observed upon 
the eyelids, have been of the infecting species. The induration of 
the base of the sore is well marked and persistent, and the accom- 
panying indurated bubo is seated in the ganglion in front of the 
ear. A case of this kind occurring at the New York Eye Infir- 
mary has been referred to in the chapter upon chancres. 

The external surface of the lids, like other portions of the 
integument, may be the seat of the various syphilitic eruptions. 
Secondary ulcers are almost always situated near the free border, 
encroaching upon the mucous membrane or upon the skin, and 
sometimes, as in a number of cases collected by Mackenzie, 1 causing 
complete destruction of the lid. I have seen but one case in a lad 
aged 19, affected with syphilitic disease of the lachrymal passages 
and nodes upon the tibia, and who had several small excavated 
ulcers upon the mucous membrane of the lower lid bordering upon 
its free margin. His disease could be traced to an infecting chan- 
cre contracted three years previous, and disappeared under iodide 
of potassium and mercurials. These ulcerations may be mistaken 
for ophthalmia tarsi, and epithelial cancer, or, when situated near 
the inner canthus, for disease of the lachrymal passages. 

Syphilitic eruptions of the eyelids are more frequent in infants 
affected with hereditary syphilis, than in adults. The external 
surface of the lids is the seat of an eruption of pustules, which 

1 Diseases of the Eve, Phil, ed., 1855, p. 160. 



AFFECTIONS OF THE CORNEA. 615 

run into each other, break and leave the skin excoriated and red. 1 
The conjunctiva of the lid and the globe may become involved 
through extension of the inflammation, and the cornea destroyed 
by infiltration of pus. This affection may be distinguished from 
ophthalmia neonatorum by its later development — the former 
appearing about the third day and the latter several weeks after 
birth — and by the presence of the eruption upon the external sur- 
face of the lids to which the conjunctivitis is only secondary. 

Affections of the Conjunctiva. — If we except the ulcera- 
tions of the margins of the lids already described as sometimes 
encroaching upon the mucous membrane of the internal surface, 
the conjunctiva is very rarely the seat of syphilitic manifestations. 

Infants tainted with hereditary syphilis are, indeed, more fre- 
quently than others the subjects of ophthalmia neonatorum; to 
which they are peculiarly exposed from their general cachectic 
condition and the frequency of vaginal discharges in their syphi- 
litic mothers; but there is no direct connection between their 
hereditary taint and the purulent inflammation of the conjunctiva, 
which usually makes its appearance before the development of 
constitutional symptoms. 

Mucous patches, so common upon other mucous membranes, are 
never met with upon the conjunctiva; this membrane, however, ac- 
cording to Desmarres, 2 is sometimes the seat of syphilitic tubercles 
coexisting with a similar eruption upon the skin. This author relates 
the case of a patient affected with syphilitic iritis, in whom one of 
the so-called condylomata of the iris, situated near its external mar- 
gin, penetrated the sclerotic and formed a protuberance beneath the 
conjunctiva, which, moreover, was studded on every side with small, 
indolent, hard and oblong tumors, exactly similar to an eruption of 
syphilitic tubercles upon various portions of the integument. The 
disease disappeared under mercurial treatment. 

Affections of the Cornea. — Mr. Jonathan Hutchinson 3 has 
expressed the opinion founded upon a lengthy and ably conducted 
series of observations, that the peculiar, inflammation of the cornea, 

1 Figured by Devergie, Clinique de la Maladie Syphilitique, PI. 37. 

2 Traite des Maladies des Yeux, t. ii. p. 216. 

3 Ophthalmic Hospital Reports, vol. i. p. 229. 



616 SYPHILITIC AFFECTION'S OF THE EYES. 

met with for the most part between the ages of. five and twenty 
and known by the name of "strumous corneitis," 1 is always due to 
hereditary syphilis. In his attempt to establish this point Mr. 
Hutchinson has attached no little importance to certain peculiarities 
in the form, size, and color of the permanent incisor teeth, which 
he regards as diagnostic of inherited syphilitic taint, and which he 
states are all but invariably coexistent with strumous keratitis. 

In describing this condition Mr. Hutchinson says : " As diagnostic 
of hereditary syphilis, various peculiarities are often presented by 
the others, especially the canines, but the upper central incisors are 

Fig. 34. 




"The teeth converge towards each other, are very short, have a vertical notch or cleft in their 
free edges, and are also very narrow from side to side at their edges, not being so wide there as at 
their necks." 

the test teeth. When first cut these teeth are usually short, narrow 
from side to side at their edges and very thin. After awhile a 
crescentic portion from their edge breaks away, leaving a broad, 
shallow, vertical notch which is permanent for some years, but be- 
tween twenty and thirty usually becomes obliterated by the pre- 
mature wearing down of the tooth. The two teeth often converge, 

Fig. 35. 




and sometimes they stand widely apart. In certain instances in 
which the notching is either wholly absent or but slightly marked, 
there is still a peculiar color ('a dirty brownish hue resembling 
that of bad size' 2 ), and a narrow squareness of form, which are 
easily recognized by the practised eye." 3 Diday 4 adduces a single 

1 The name " Keratitis " is much preferable to "Corneitis." 

2 Hutchinson, on the Means of Recognizing the Subjects of Inherited Syphilis in 
Adult Life, Medical Times and Gaz., Sept. 11, 1858, p. 265. 

3 Ophthalmic Hosp. Reports, vol. ii. p. 96. 
* Gaz. Hebdom., Feb. 4, 1860. 



SYPHILITIC IRITIS. 617 

case in confirmation of Mr. Hutchinson's observations upon stru- 
mous corneitis and notching of the teeth as symptomatic of heredi- 
tary syphilis. 

In justice to the importance of this subject, and to Mr. Hutchin- 
son's laborious researches, no decided opinion for or against his 
statements would be warrantable, unless based upon an equally 
thorough series of investigations, which I have not as yet found 
time to undertake, although I hope soon to be able so to do at the 
New York Eye Infirmary, than which no better field is anywhere 
afforded. I may be permitted, however, to give my own impres- 
sions, which are shared by my colleagues at the Infirmary, that the 
peculiarity of the teeth, above described, is a symptom of general 
cachexia, which may be occasioned by other causes than syphilis, 
and that strumous keratitis is observed in subjects in whom there 
can be no suspicion of inherited taint ; although I can fully confirm 
Mr. Hutchinson's statement, that the most efficacious treatment of 
this disease, in the majority of cases, is by means of mild mercurials 
and iodide of potassium, assisted by nourishing diet, fresh air, and 
tonics. 

Syphilitic Iritis. — Syphilitic iritis, endangering, as it does, the 
integrity of one of the most important organs of the human frame, 
should be familiar to every student of venereal, that he may early 
be able to recognize and treat it. A knowledge of its symptoms 
may, I think, be best imparted by a concise description, in which 
its prominent features, whereon the diagnosis must be based, shall 
be alone included, omitting the more minute details which are 
chiefly of interest to the ophthalmologist, and which are apt to 
confuse the mind of one who has not made a special study of the 
eye. 

Let me premise by saying that we have no certain means of 
distinguishing syphilitic iritis from that dependent upon injury, 
scrofula, or other causes; although there are certain symptoms, 
presently to be described, which, when observed, render the former 
origin probable. Moreover, the majority of cases of iritis are doubt- 
less due to syphilitic taint, 1 so that the existence of this disease 

1 My friend, Dr. Henry D. Noyes, of the Infirmary, informs me that, according 
to statistics collected by Prof. Grraefe, and reported by him in his lectures, about 
sixty per cent, of all cases of iritis occur in persons affected with syphilis. 



618 SYPHILITIC AFFECTIONS OF THE EYES. 

should always excite suspicion, and lead the surgeon to make a 
thorough examination of the present condition and past history of 
the patient. 

Two forms of iritis are admitted. 

The first, which is the most common and most worthy of our 
attention, is to be ranked among the secondary symptoms of syphi- 
lis. Without being able to furnish any statistics from which the 
exact time of its development may be determined, yet I have often 
been struck with the fact that, when no mercury had been adminis- 
tered, this occurred somewhere about six months after contagion. 
In a number of instances, iritis has been the first general symptom 
which has induced patients to seek surgical advice, but careful 
inquiry has never failed to show that other symptoms, as alopecia, 
engorgement of the cervical ganglia, mucous patches, erythema, or 
papules, had preceded it, although regarded at the time as of no 
importance. 

The most prominent symptoms of this disease are the follow- 
ing:— 

Injection of the conjunctival and sclerotic vessels, giving the eye 
a red appearance. But unnatural redness is observed in simple 
conjunctivitis; and how shall the two be distinguished? In the 
first place, by depressing the lower lid, and, at the same time, tell- 
ing the patient to look upwards ; whereby the inferior palpebral 
fold will be exposed. In most cases of conjunctivitis, the greatest 
amount of injection will be found remote from the cornea; while 
in iritis the contrary is the case ; the redness is almost entirely con- 
fined to a circle round the cornea, called the "sclerotic zone," while 
the more distant portions of the white of the eye remain clear. If 
the eye has been congested by the injudicious application of poul- 
tices, alum curds, etc., this difference will be less, or not at all, 
apparent. Again, observe the character of the injection: some of 
the conjunctival vessels are distended, and may be recognized by 
their brick-red color, large size, tortuous course (chiefly over the 
recti muscles), and their mobility, if the conjunctiva, by means of 
slight pressure with the finger external to the lid, be made to slide 
over the sclerotica; but beneath these brick-red vessels a second 
layer is discovered on close examination, composed of others radi- 
ating from the margin of the cornea, much finer than the preceding, 
straight, and of a pinkish hue, and which are seen to remain sta- 
tionary through the meshes of the sliding network of conjunctival 



SYPHILITIC IRITIS. 619 

vessels. It is these vessels which constitute the sclerotic zone, met 
with not only in iritis, but in other internal inflammations of the 
eye. 

Next observe the condition of the iris and pupil and compare 
them with those of the opposite and sound eye. The affected iris 
is seen to have lost its natural brilliancy ; its minute texture is 
less apparent ; its surface covered over with a thin layer of fibrin ; 
and its color changed. In persons with blue eyes it assumes a 
yellowish green hue ; in others, the change is less marked but may 
generally be detected. Close the two eyes with the thumb of each 
hand, the fingers resting for support upon the temples, and alter- 
nately open one and then the other ; and the iris of the affected eye 
will be found to be sluggish in its motions or quite immovable. 

At a later stage of the disease one or more yellowish or brownish 
elevations may begin to appear upon the surface of the iris, and 
generally, though not always, upon its inner ring near the margin 
of the pupil. These " tubercles," as they are called, gradually in- 
crease in size and sometimes become organized and covered with 
a minute network of vessels. If seated near the external border 
of the iris they may cause projection of the cornea or sclerotica. 
Graefe states that they are composed of fibrinous exudation, gran- 
ular amorphous matter and pus-corpuscles. 1 Virchow 2 believes 
that they are dependent upon a deposit of syphilitic tubercle in the 
substance of the iris, but this opinion cannot be received without 
further proof. They are very much more frequent in syphilitic 
than in iritis from other causes, 3 but are not exclusively confined 
to the former, hence their presence affords a strong probability 
though not an absolute certainty of syphilitic taint. 

At an early stage of the disease, the pupil assumes a dull ap- 
pearance, and is less clear and bright than natural, owing to com- 
mencing changes in the anterior capsule of the lens ; it may also 
be somewhat irregular. This irregularity of outline, due to adhe- 
sions between its margin and the capsule of the lens, becomes more 
marked as the disease progresses, and is especially evident if the 
pupil be dilated by belladonna, when its margin is found to be 
scalloped owing to its being attached at some points and drawn out 

1 Notes of Graefe's Lectures for which I am indebted to Dr. Henry D. Noyes. 

2 La Syphilis Constitutionnelle, p. 146. 

3 Of sixty cases of iritic tubercles collected by Graefe, in only two was there no 
proof of syphilitic taint. Notes of Graefe's Lectures. 



620 SYPHILITIC AFFECTIONS OF THE EYES. 

in others. In some cases the adhesions become continuous around 
the whole circumference, and the capsule of the lens is covered with 
a layer of lymph which completely blocks up the pupil. 

When syphilitic iritis is early and successfully treated, the iris 
resumes its normal mobility and color, and the eye is restored to 
its original integrity. But in weak and cachectic subjects and in 
the absence of appropriate treatment, the changes which take place 
are more or less permanent. The tubercles are absorbed but the 
iris never regains its original color and consistency ; it is thinned 
and friable ; and its adhesions to the capsule, unless stretched or 
broken by the persevering use of mydriatics, permanently impede 
the motions of the pupil. As a general rule, the pain and photo- 
phobia in syphilitic iritis are much less than in the other forms of 
the disease. The patient may merely complain of a sense of fulness 
and uneasiness in the globe and shrink from exposure to a strong 
light only. In other cases, severe pain is felt in the ball of the eye 
and in the temporal and supra-orbital regions, and the least ray of 
light causes the most intense suffering ; the variations between these 
two extremes are numerous. There is almost invariably some 
dimness of vision which is due not only to the changes in the 
capsule of the lens, but also to those in the deeper structures of the 
eye which are always involved to a greater or less extent. 

Iritis usually presents such marked symptoms that it is easily 
recognized by any competent person ; and yet every ophthalmic 
surgeon must have met with not unfrequent instances in which 
through carelessness or ignorance it has been mistaken for simple 
conjunctivitis and treated solely with colly ria of nitrate of silver, 
sulphate of zinc, etc. A few cases, however, are met with in which 
the most experienced surgeon may for a day or two fail to make a 
diagnosis. This generally occurs at the commencement of the dis- 
ease, before any marked changes have taken place in the iris, and 
especially when the conjunctival vessels have been congested by 
the application of poultices. I have seen a number of such cases 
at the N". Y. Eye Infirmary, in some of which attention has been 
expressly called to the obscurity of the symptoms and the necessity 
of waiting a day or two before deciding as to the nature of the dis- 
ease ; while in others it has been determined not from the appear- 
ance of the eye itself, but from the discovery of some syphilitic 
symptom, as a mucous patch, a copper- colored eruption, or an 
enlarged post-cervical gland. I would repeat, however, that such 



SYPHILITIC IKITIS. 621 

cases are very rare, and that the obscurity is almost invariably due 
to improper applications to the eye. 

I have already remarked that the diagnosis of syphilitic iritis, 
although rendered highly probable by the absence of severe pain 
and photophobia, and the presence of tubercles upon the iris, can 
only be satisfactorily established by the history of the case or the 
coexistence of undoubted syphilitic symptoms. I would also 
add that the presence of any general eruption upon the body 
leaves scarcely room to doubt that a coexisting iritis is of spe- 
cific origin, since this disease, when due to other causes, is very 
rarely accompanied by affections of the skin. The practical surgeon 
when called to treat a case of iritis, almost instinctively turns to 
the arms, chest, and abdomen, to look for traces of one of the 
syphilodermata. 

The second form of iritis, to which I have referred, is met with 
as a symptom of tertiary syphilis, and differs from the preceding 
chiefly by the insidious manner in which it attacks the eye, and by 
its greater persistency. There is almost a complete absence of pain 
and photophobia; the iris becomes infiltrated and covered with 
lymph, and has a peculiar swollen and velvety appearance ; nu- 
merous adhesions take place between its pupillary margin and the 
capsule of the lens ; and the irregular pupil is blocked up with an 
effusion of lymph, upon which small, black, uveal deposits may 
often be detected. Both eyes are generally attacked in succession; 
the disease is exceedingly persistent, and with difficulty controlled 
by treatment ; and the danger of complete loss of sight from ob- 
struction of the pupil is very great. The deeper structures of the 
eye appear to be implicated to a less extent than in the acute form. 

Among the absurdities of medical belief that have had their day 
is to be reckoned the idea that mercury may give rise to iritis — a 
disease which is often met with when no specific remedy has been 
employed, and which can in no way be better controlled than by 
the judicious use of mercurials ; indeed, the surgeon rarely has an 
opportunity of witnessing a more remarkable effect of treatment 
than is seen in the absorption of lymph, the disappearance of the 
abnormal injection, and the restoration of the iris to its original 
condition, which take place under the administration of mercury in 
acute syphilitic iritis. It is hardly necessary to say that an agent 
of so much good is capable of doing a great amount of harm, and 
that I am here speaking of its use and not of its abuse. 



622 SYPHILITIC AFFECTIONS OF THE EYES. 

The plan of treatment of the acute form of iritis which I have 
found almost uniformly successful, has, for its objects — 

1. To bring the system under the influence of mercurials as 
speedily as possible, without injury to the general health, and with- 
out inducing salivation. 

2. In a depressed state of the system, to combine tonics with 
mercurials, or to employ the former in connection with iodide of 
potassium instead of the latter. 

3. To keep the pupil constantly dilated by means of atropine or 
belladonna, and thus prevent adhesions between the iris and capsule 
of the lens. 

4. To relieve pain and regulate the general hygienic management 
of the case. 

The subjects of these different heads will be somewhat briefly 
considered in view of the fact that most of them have been included 
in what has been said of the general treatment of syphilis. 

In persons of a fair state of health, no form of mercurial is pref- 
erable to the ordinary pill of calomel and opium (one grain of the 
former to a quarter or half a grain of the latter) administered three 
times a day — an hour after meals. "When the general condition of 
the system is depressed, a tonic should be combined with the mer- 
curial ; and the following formulae are most frequently employed 
at the N. Y. Eye Infirmary, where the patients are, for the most 
part, of the poorer class, and under unfavorable hygienic influ- 
ences :- — 

I£. Hydrargyri cum creta gr. ij. 

Quiniae sulphat. gr. j. 
M. et ft. plv. 

]£. Hydrargyri cum creta gr. ij. 

Quiniae sulpha tis gr. j. 

Pulveris Doveri gr. iij. 
M. et ft. plv. 

The latter formula containing Dover's powder is to be preferred 
when the pain is severe. The frequency of the administration of 
these powders is to be determined by the strength and general 
condition of the patient. Under ordinary circumstances, one may 
be given three times a day ; or, when the system is much depressed, 
one morning and night, with one or two grains of quinine in addi- 
tion twice during the day ; and when thus guarded by quinine, 
mercury may be employed in nearly every case of this disease. It 



SYPHILITIC IRITIS. 623 

is well to prolong the use of this remedy until evidence of its action 
upon the mouth is perceptible, but not to continue it until salivation 
is produced. So soon as the gums are decidedly affected, the mer- 
curial should be suspended,, and chlorate of potash employed, while 
at the same time the tonic may be continued. 

It is a singular fact, that the opposite eye will sometimes be at- 
tacked while the patient is taking mercury for the one first affected, 
and, in rare instances, even during the existence of ptyalism. 

It will be observed that the above mode of employing mercury 
in combination with quinine, as practised for many years at the 
New York Eye Infirmary, is widely different from the exclusive 
use of this mineral, which has been recommended by some authors. 
It would be out of place in the present work to enter into a discus- 
sion of the comparative merits of the two methods, and I must, 
therefore, content myself with expressing a strong preference for 
the one here proposed ; merely adding, that it is equally as true of 
iritis, as of other syphilitic manifestations, that the administration 
of mercury, without regard to the condition of the patient, is quite 
as likely to do harm as to do good. 

My friend, Dr. Henry W. Williams, of Boston, has adduced sixty- 
four cases of iritis, dependent upon various causes, to show that the 
treatment of this disease may be successfully conducted without 
mercury, by means of quinine, iodide of potassium, narcotics, and 
mydriatics. There appears to be no good reason why we should 
lay aside so valuable an agent as mercury, provided it be not 
abused. In a large number of cases of iritis, treated by my 
colleagues and myself, at the Infirmary, I have never seen any 
unfavorable influence upon the general health; and repeated trials 
of Dr. Williams's method by Dr. C. E. Agnew and myself, have 
convinced us both that the results are less satisfactory than when 
mercury is employed. In two instances, permanent impairment of 
vision ensued, which we had reason to believe might have been 
prevented by the use of mercurials ; and in all the duration of the 
disease was considerably prolonged. 

It is of the first importance in the treatment of iritis to maintain 
the pupil in a constant state of dilatation, so as to remove the iris 
as far as possible from the convex surface of the lens, and prevent 
adhesions or closure of the pupil with lymph. For this purpose, 
instillations of a solution of atropine are far preferable to extract 
of belladonna smeared upon the brow. In addition to its power of 



624 SYPHILITIC AFFECTIONS OF THE EYES. 

dilating the pupil, atropine is a most valuable sedative — a rare 
combination in the same remedy. Two grains to the ounce of 
distilled water, first dissolved in a few drops of dilute acetic acid, 
or, better still, in a little alcohol, is the formula which I com- 
monly employ. This solution is best applied to the inner canthus 
by means of a camel's hair brush; in default of which, the pa- 
tient's head may be thrown back, and a small portion of the fluid 
be poured upon the concavity upon the side of the nose, when 
some of it may readily be made to flow between the lids. If the 
case be seen at the outset, before the motions of the iris are im- 
peded by an infiltration of lymph, two or three times a day will be 
sufficiently often to use the drops. In the acute stage of iritis, some 
authors advise us entirely to abstain from the use of atropine and 
belladonna, which have but little power of influencing the pupil 
after effusion has taken place, and which, it is said, may "irritate 
and tease the iris, and cause pain." 1 My own experience leads me 
to believe that these fears are groundless. Instead of aggravating, 
I believe that atropine greatly relieves the pain and irritation, and 
although its immediate action upon the pupil is not perceptible, 
yet it gradually stretches or breaks down the adhesions already 
formed, and thus assists the iris in recovering its dilatability ; hence 
I am in the habit of even increasing the frequency of the instilla- 
tions, during the acute stage, to three or possibly four times a day. 
Care should be taken, however, that the atropine, some of which 
gains the pharynx through the lachrymal and nasal passages, does 
not produce its physiological effects upon the general system. 

Venesection is never required in syphilitic iritis, and local deple- 
tion by means of cups and leeches is advisable in only a few cases 
in robust subjects. After the acute stage has passed, counter- 
irritation is best effected by painting the brow with the strong 
tincture of iodine. 

It is highly important that the patient should obtain sleep, for 
which purpose ten grains of Dover's powder may be given at bed- 
time, and repeated if necessary. In many cases, however, frictions 
upon the brow and temple at bedtime of mercurial ointment, with 
the addition of powdered opium (ung. hydrarg. Ij, plv. opii 3j) will 
suffice to allay pain and procure sleep. 

In this, as in nearly all affections of the eye, the surgeon has to 

1 Ckitchett, Lectures on Diseases of the Eye, London Lancet, Am. ed., March, 
1855, p. 216. 



INFANTILE IRITIS. 625 

contend with the deeply-rooted prejudices of the masses in favor of 
poultices of bread and milk, tea leaves, alum curds, raw oysters, 
pieces of pork, et id genus omne. Not only should all such vile 
applications be put far away, but the eye should not be tied up 
with handkerchiefs or cloths in any manner. In women, the best 
protection against the strong light is a veil; in men, a pasteboard 
shade will answer the same purpose. 

In unfavorable weather, or in unusually severe cases of iritis, the 
patient should be confined to the house, or even to his room, which 
should be shaded but not darkened. In most cases, however, when 
the weather is fair, it is desirable that the patient should pass a 
portion of the day out of doors, in the early morning or evening, if 
the intolerance of light be excessive, and with the eyes protected in 
the manner above directed. Photophobia and irritability of the eye 
will be aggravated by confinement to a dark room. 

The diet must be proportioned to the general condition of the 
system. Eobust subjects should take but a small quantity of light 
food ; while the cachectic require an abundant supply of nourish- 
ment and, it may be, stimulants. Proper attention should also be 
paid to the digestive organs, and a daily evacuation of the bowels 
secured. 

The chronic form of iritis met with in tertiary syphilis most fre- 
quently occurs in persons whose constitution is enfeebled, and by 
whom mercury is poorly tolerated ; but when properly guarded by 
tonics, this mineral may still, in many cases, be used with marked 
benefit ; in others we are obliged to resort to iodide of potassium, 
until by every available means the general health is restored. 
Mercurial inunction may often be employed, when mercury by the 
mouth cannot be borne. 

I must refer the reader to works upon ophthalmic surgery for a 
description of the operations intended for the relief of closure of 
the pupil, the effect of iritis. 

Infantile Iritis. — An extremely interesting form of iritis is met 
with in infants affected with hereditary syphilis. It is a rare disease, 
but probably exists in many instances in which it is overlooked. 
All the cases hitherto reported are included in the following table, 
prepared by Mr. Jonathan Hutchinson ; and the conclusions deduci- 
ble from them are from the pen of the same author. 1 

1 Medical Times and Gaz., July 14, 1860. 
40 



626 



SYPHILITIC AFFECTIONS OF THE EYES. 



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628 SYPHILITIC AFFECTIONS OF THE EYES. 

Mr. Hutchinson deduces the following conclusions from the above 
series of cases : — 

1. That the subjects of infantile iritis are much more frequently 
of the female than the male sex. 

2. That syphilitic infants are most liable to suffer from iritis at 
about the age of five months. 

3. That syphilitic iritis in infants is often symmetrical, but quite 
as frequently not so. 

4. That iritis, as it occurs in infants, is seldom complicated, and 
is attended by but few of the more severe symptoms which charac- 
terize the disease in the adult. Haziness of the cornea and photo- 
phobia, which are common in adults, are rare in infants, in whom 
there is also but little pain and sclerotic injection. 

5. Notwithstanding the ill-characterized phenomena of acute 
inflammation, the effusion of lymph is usually very free, and the 
danger of occlusion of the pupil great. 

6. Mercurial treatment is most signally efficacious in curing the 
disease, and, if recent, in procuring the complete absorption of the 
effused lymph. 

7. Mercurial treatment previously adopted does not prevent the 
occurrence of this form of iritis. 

8. The subjects of infantile iritis, though often puny and cachec- 
tic, are also often apparently in good health. 

9. Infants suffering from iritis almost always show one or another 
of the well-recognized symptoms of hereditary taint. 

10. Most of those who suffer from syphilitic iritis are infants 
born within a short period of the date of the primary disease in 
their parents. This accords with what is observed in the iritis of 
adults, which, in a great majority of instances, is a secondary, and 
not a tertiary symptom. 

I have seen only one instance of this affection in an infant at the 
Infirmary, who was not brought a second time, and whose case I 
was therefore unable to follow out. I have at present in charge a 
case of double chronic iritis in a boy aged 10, affected also with 
engorgement of the cervical ganglia, who, as reported by his father, 
was said, by the attending physician (Dr. Gr. L. Bedford), to have 
contracted syphilis from his wet-nurse. I may mention incidentally, 
that his teeth are generally misshapen, and that one of his upper 
incisors is completely perforated by a small hole about one-third of 
its length from its lower margin. 



RETINITIS AND CHOEOIDTTIS. 629 

Ketinitis and Choroiditis. — The subjective symptoms of 
these two affections are often so slightly marked at their commence- 
ment as to attract but little attention either from the patient or 
surgeon, and irreparable mischief may be done before their gravity 
is fully appreciated. I have repeatedly met with cases of constitu- 
tional infection in which some slight complaint from the patient has 
led to an ophthalmoscopic examination of the eye disclosing the 
existence of a disease which threatened the loss of sight, but which 
was subsequently arrested by appropriate treatment. 

The symptoms of retinitis and choroiditis of syphilitic origin 
do not differ from those of the same affections dependent upon 
other causes. In most cases, the patient first perceives a fog or 
mist before the sight, attended perhaps by a sensation of fulness in 
the globe, muscse and frontal headache or hemicrania ; the excessive 
photophobia formerly insisted on as a symptom of retinitis is rarely 
present ; the obscuration of vision gradually progresses until finally 
the capability of distinguishing between light and darkness alone 
remains, or the eye becomes entirely blind. These subjective 
symptoms cannot enable us to distinguish between retinitis and 
choroiditis, which have only quite recently been recognized by the 
use of the ophthalmoscope, which has rendered the examination of 
the deeper structures of the eye nearly as easy as that of the ex- 
ternal. 

In order to explain the ophthalmoscopic appearances of retinitis, 
it is necessary to premise, that in a state of health, the retina, which 
is an expansion of the optic nerve, is perfectly transparent and 
enables us to see through it the abrupt margin of the sclerotica, 
forming the boundary of the optic disk — the whitish circle visible 
upon ophthalmoscopic examination at the fundus of the eye. Now 
the natural effect of inflammation upon this transparent membrane 
is to give it increased vascularity, and cause effusion into its sub- 
stance and render it opaque. Hence one of the earliest signs of 
retinitis is increased redness, which may commence either upon the 
optic nerve-entrance imparting to it a pinkish hue, or peripherally 
in the retina ; the vessels, both arteries and veins, which emerge 
from the optic disk to be distributed to the retina are also abnor- 
mally enlarged and injected ; and at certain points of their course 
they are lost to view, owing to the opacity of the retinal tissue 
which covers them. Their rupture may also give rise to small 
patches of ecchymosis. Again, effusion into the substance of the 



630 SYPHILITIC AFFECTIONS OF THE EYES. 

retina first impairs its transparency, and produces the appearance 
of a fog or haze in the fundus of the eye, and finally entirely con- 
ceals the entrance of the optic nerve, the site of which can only be 
determined by the convergence of the dilated veins. The ob- 
scurity of the deeper structures may also be increased by transuda- 
tion into the vitreous humor. 

The ophthalmoscopic appearances of choroiditis are very numer- 
ous, but are nearly all dependent upon various degrees of atrophy 
of the choroid, permitting the white sclerotic to be seen through 
the thinned portions. At an early stage of the disease, when the 
atrophy is confined to the internal and pigmentary layers of the 
choroid, a condition known as "maceration of the pigment of the 
choroid" is seen; the coloring matter is distributed irregularly, 
thinned in some portions and aggregated in others, giving the 
fundus of the eye a mottled or watered appearance, as if sprinkled 
with ink. Again, the atrophy may be confined to circumscribed 
patches, of an almost pearly white color and in striking contrast 
with the general pinkish hue of the fundus of the eye ; or it may 
be general, in which case the internal chamber of the organ of sight 
reflects an unusual amount of light. Deposits of lymph in the 
substance of the choroid may also give rise to light-colored patches, 
similar to those produced by atrophy ; but the former may be re- 
cognized from the fact that they conceal the choroidal and retinal 
vessels, which in the latter may be seen to cross the patch. ' 

Exudation from the choroidal vessels may produce sub-retinal 
effusions, which are generally limited to one portion of the fundus 
and prevent vision in the opposite direction ; for instance, if the 
effusion be situated externally, the patient can see outwards but 
not inwards ; if inferiorly, he can see downwards but not upwards. 
These effusions present a very characteristic appearance before the 
ophthalmoscope and resemble a large semi-transparent bleb or bulla, 
encroaching upon the vitreous and oscillating to and fro. The 
retinal vessels may be seen leaving the attached retina and ascend- 
ing upon the surface of the detached portion. 

The use of the ophthalmoscope has as yet been so little extended, 
that it is not to be expected that the above symptoms can always 
be recognized by the general practitioner. The important facts to 
be borne in mind are these : that the instrument referred to has 
demonstrated the existence of deep-seated changes in the eye pro- 
duced by constitutional infection and threatening the loss of sight ; 



PARALYSIS OF THE MOTOR NERVES OF THE EYE. 631 

and hence that any impairment of vision in syphilitic subjects, 
although unattended by symptoms of external inflammation, should 
at once put the surgeon upon his guard and lead him to resort to 
specific remedies. 

I have met with several cases of syphilitic retinitis occurring at 
various intervals after iritis. The wife of the patient referred to 
upon page 370, suffered from this disease fifteen months after her 
attack of iritis, and at a time when no other syphilitic symptoms 
were present. In this case the disease was promptly removed by 
mercurials ; and the prognosis is generally favorable in otherwise 
healthy persons, provided specific remedies be employed in time. 
Indeed, with respect to the success attending appropriate treatment, 
syphilitic choroiditis and retinitis resemble syphilitic iritis. 

Syphilitic Amaurosis. — Before the invention of the ophthal- 
moscope most cases of choroiditis and retinitis were included under 
the name of amaurosis, which is now properly limited to a loss of 
vision dependent upon disease of the optic nerve or brain, without 
appreciable lesion of the tunics of the eye. 

In the amaurosis of syphilitic subjects, the use of the ophthal- 
moscope can sometimes discover nothing abnormal in the condition 
of the fundus of the eye ; while in other cases, the optic nerve is 
found to be atrophied, as shown by its diminution of volume, its 
cupped surface, its peculiarly white and opaque color, and the 
small size of the central vessels — especially the arteries, .When 
this condition exists the prognosis is very unfavorable, and but 
little effect can be expected from treatment. 

Paralysis of the Motor Nerves of the Eye. — It is a frequent 
remark of my esteemed friend Dr. Abram Du Bois, who, from his 
long attention to diseases of the eye both in private practice and 
at the New York Eye Infirmary, is eminently qualified to judge, 
that a large proportion of cases of paralysis of the motor nerves of 
the eye are due to syphilis ; and this statement is fully confirmed 
by my own more limited experience. Graefe 1 also attributes this 
class of affections to constitutional taint "in nearly half of all the 
cases met with." 

In most instances, it is the third pair, or motor oculi, that is 

1 Syphilitic Affections of the Eye, Deutsche Klinik, 1858, No. 21. 



632 SYPHILITIC AFFECTIONS OF THE EYES 

affected ; next in order of frequency comes the sixth pair, or abdu- 
cens; 1 and finally the fourth pair, or patheticus. 

My limited space compels me to refer the reader to treatises upon 
diseases of the eye for a description of the symptoms of these affec- 
tions. 2 I will merely remark, that the surgeon should carefully 
avoid confounding paralysis of the sixth pair with converging stra- 
bismus. The two may readily be distinguished by the fact that, 
in the former, the patient is unable, under any circumstances, to 
turn the eye outwards; while, in the latter, if the straight eye be 
covered, the squinting eye resumes its normal direction. Atten- 
tion to this point will enable the surgeon to avoid an error which 
I have known to be committed, viz., that of resorting to division of 
the internal rectus, which can be of no use whatever while the ex- 
ternal rectus is paralyzed. 

The pathology of paralysis of the motor nerves of the eye is 
often obscure. Dixon 3 relates two highly interesting cases, in which 
examination after death revealed the existence of tumors (supposed 
to consist of syphilitic tubercle) in the substance of the nerve. The 
paralysis is rarely due to disease of the bony passages, or their lin- 
ing membrane, traversed by the nerve, but has been traced upon 
post-mortem examination to softening of the nervous or cerebral 
tissue. Virchow 4 quotes a number of cases dependent upon the 
last-mentioned cause. 

These affections of the motor nerves are generally met with in 
the tertiary stage of syphilis, and in most cases yield to iodide of 
potassium; indeed the facility with which they are affected by 
treatment, would seem to preclude the idea that they are neces- 
sarily dependent upon serious organic changes either in the nerve 
or brain. 

1 Dr. Beyram has related three interesting cases of paralysis of the sixth pair 
due to syphilis, L'Union Medicale, Feb. 23, 1860. 

1 See an able article, by Dr. Wells, giving an account of Graefe's researches 
upon paralytic affections of the eye, Ophthalmic Hospital Reports, vol. ii. p. 44. 

3 Med. Times and Gaz., Oct. 23, 1858. 

4 Syphilis Constitutionnelle, p. 129 et seq. 



SYPHILITIC AFFECTION'S OF THE EAR. 633 



CHAPTER XIII. 

SYPHILITIC AFFECTIONS OF THE EAR. 

Patients not unfrequently complain of deafness suddenly su- 
pervening in the course of general syphilis, and evidently de- 
pendent upon the constitutional taint, since it coincides with well- 
marked syphilitic manifestations, and yields to specific remedies. 
In most of these cases, as ordinarily met with in practice, the dis- 
ease consists in inflammation of the tympanal membrane, as is 
evinced by the abnormal redness and vascularity of the drum, if 
an examination be made of the external auditory canal. For this 
purpose a tubular speculum (either Mr. "Wilde's or Mr. Toynbee's) 
is far preferable to a bivalve instrument, and the ear should be 
exposed to the direct rays of the sun. As a general rule, the ac- 
companying pain is less than in acute myringitis of simple origin, 
and in some instances is entirely absent; but in others it is very 
severe, radiating over the side of the head, and increased by cough- 
ing, sneezing, swallowing, blowing the nose, pressure in front of 
the meatus, and the motions of the jaw. There is no abnormal 
discharge from the external ear. If the disease be allowed to go 
on unchecked, lymph may be effused between the lamellae of the 
drum, producing permanent impairment of hearing. 

Mr. Wilde, of Dublin, in his able work upon diseases of the ear, 1 
was the first to call attention to this affection, and to show that the 
deafness arising in the course of constitutional syphilis is, in most 
cases, dependent upon myringitis, and not, as was commonly sup- 
posed, upon obstruction of the Eustachian tube from inflammation 
or ulceration of the fauces. A number of cases have been observed 
by my colleagues and myself, at the New York Eye Infirmary, and 
I have met with others in private "practice, in which the truth of 
Mr. Wilde's statement has been fully confirmed, and in which the 

1 Practical Observations on Aural Surgery, etc., Phil., 1853, p. 252. 



634 SYPHILITIC AFFECTIONS OF THE EAR. 

pathology of the disease could not be mistaken. I feel obliged to 
dissent ; however, from this author's assertion that syphilitic myrin- 
gitis is "unaccompanied by local pain," which, although generally 
less than in simple acute myringitis, was quite severe in several of 
the cases referred to — a point which has also been confirmed by my 
friend, Dr. C. K. Agnew. 

The character of the co-existing symptoms, and the amenability 
of the disease to mercury, indicate that syphilitic myringitis should 
be ranked among secondary lesions; indeed, its position in the 
syphilitic scale may be regarded as nearly identical with that of 
the secondary form of iritis, with which it possesses several points 
of analogy. 

The treatment of this affection consists in the active employment 
of mercurials internally, together with opiates, if required for the 
relief of pain ; and in the external application of leeches in front of 
the tragus, or within the meatus auditorius, followed by poultices 
or hot fomentations. When the acute inflammation has been sub- 
dued, if any effusion of lymph be visible in the substance of the 
drum, or if the function of the organ be not completely restored, 
the administration of iodide of potassium, and blisters behind the 
ear, should be resorted to. 

In addition to the manner now described, the ear may be indi- 
rectly implicated by secondary ulcerations of the meatus, by the 
extension of phagedenic ulcers of the pharynx to the Eustachian 
tube and tympanum, and by ostitis or caries of various portions of 
the temporal bone; but these affections are rare, and their full 
description would exceed the limits of the present work. Most 
of the cases reported by authors, may be found collected in the 
work of M. Gustave Lagneau, fils, upon syphilitic affections of the 
nervous system. 1 

1 Maladies Syphilitiques du Systeme Nerveux, Paris, 1860, p. 295. 



SYPHILITIC ORCHITIS. 635 



CHAPTER XIV. 

SYPHILITIC ORCHITIS. 

A DISEASE of the testicle, dependent upon constitutional syphilis, 
was recognized by Astruc, 1 who speaks of its indolent character, 
and contrasts it with the acute inflammation of gonorrhoeal testicle ; 
it was unknown to Hunter, but was noticed by Bell, 2 and, more 
recently, has been described by Sir Astley Cooper, 3 Berard, 4 Yel- 
peau, 5 and others ; but our present knowledge of this affection is 
chiefly due to Eicord, who has given a most faithful description of 
its symptoms, pathology, and treatment, under the name of syphi- 
litic albuginitis. 

Syphilitic sarcocele, orchitis, or albuginitis, as it is variously 
termed, is one of the so-called transition symptoms of syphilis, on 
the confines between secondary and tertiary lesions, but more 
closely allied to the latter than the former. When the constitu- 
tional disease runs a rapid course, it may sometimes occur as early 
as the fourth or fifth month after contagion, while secondary symp- 
toms are still present ; but, in the majority of cases, it does not 
appear until several years after the primary sore, and is accom- 
panied by well-marked tertiary manifestations in the fauces, perios- 
teum, or bones ; or, in some instances, it stands alone as the only 
evidence that the patient is still affected with the syphilitic dia- 
thesis. The statement that "it may appear at the same time with 
primary chancre," or, in other words, that an infecting chancre and 
syphilitic orchitis, due to the same contagion, may be developed 
contemporaneously, is too absurd to require refutation. 

1 Book III., chap. iv. 

2 Treatise on Gonorrhoea Virulenta and Lues Venerea, vol. ii. p. 128. 

3 Structure and Diseases of the Testis. 

4 Des divers Engorgements du Testicule, Paris, 1834. 
6 Dictionnaire de Med. 



636 SYPHILITIC OKCHITIS. 

Symptoms. — In most cases, syphilitic orchitis attacks both testi- 
cles either at the same time or consecutively. Its symptoms are 
deserving of special attention, since it may readily be confounded 
with other affections of the testis which require extirpation. The 
records of surgery show that many testicles have been removed for 
what is now known to be an essentially curable disease. 

One of the most characteristic features of this affection is the 
almost entire absence of pain attending it and the great insensi- 
bility to pressure ; so much so, that whenever a testicle becomes 
enlarged without any of the ordinary signs of inflammation in a 
person who has once had constitutional syphilis, there is strong 
reason to suspect that the disease is due to syphilitic taint. In 
exceptional instances, a dull pain is felt about the loins, but gen- 
erally the only uncomfortable sensation is a feeling of weight in the 
affected organ, which is worse towards evening after the patient 
has been upon his feet during the day, but which does not undergo 
the nocturnal exacerbation so common to syphilitic pains situated 
in the periosteum and bones. Moreover as the disease progresses, 
the testicle appears to lose even its normal sensibility, and may 
be roughly handled without causing the slightest uneasiness. 

Another important feature is the entire absence of morbid 
changes in the scrotum, vas deferens, and epididymis. The healthy 
condition of the cord and of the covering of the testicle is evident 
throughout the whole course of the disease ; the same fact may be 
established relative to the epididymis at the commencement, and 
still holds good at a later period, although, when the swelling at- 
tains a considerable size, it is sometimes impossible to distinguish 
the different portions of the organ. 

The body of the testicle, which is always the part affected, is 
somewhat increased in size but never to the same extent as in en- 
cephaloid disease of the same organ ; and it rarely exceeds twice 
its normal diameter. Eicord was in the habit of saying at his 
lectures, "Whenever you meet with a tumor of the testis as large 
as your fist, and find that the swelling is not in a great measure 
due to effusion, you need not suspect syphilis." In most cases, a 
small portion of the apparent swelling is dependent upon hydro- 
cele ; since in nearly every instance of syphilitic orchitis, there is 
a slight effusion into the tunica vaginalis. When the amount of 
fluid is considerable, it may be necessary to evacuate it by punc- 
ture with a broad needle before a satisfactory examination can be 



SYMPTOMS. 637 

made ; but in most cases, we may by firm pressure sufficiently dis- 
place the fluid to reach the body of the testicle and determine its 
condition by palpation. At an early stage of the disease, the tes- 
ticle is found to contain one or more distinct masses of induration, 
which may form slight projections upon the surface, of the size of 
the head of a pin, pea, or even an almond, but which are never so 
prominent as to change the general contour of the organ. These 
projections are due to an effusion of plastic material, of the same 
nature as gummy tumors, upon the surface of the tunica albuginea. 
As the disease progresses, the distinct masses of induration coalesce 
and form a hard resistant tumor, which still preserves to a great 
extent the normal shape of the testicle. 

The course of this affection is exceedingly slow and chronic, fre- 
quently lasting for several years. The sexual desires are not 
changed, unless the disease has made great progress in both testi- 
cles. 

When recognized at a sufficiently early period, syphilitic orchitis 
may almost invariably be arrested and the organ restored to its 
original integrity. If left to itself it most frequently terminates in 
obliteration of the seminiferous tubes, and complete or partial 
atrophy corresponding to the extent of the adventitious deposit ; or, 
again, the parenchyma of the gland may degenerate into fibrous, 
cartilaginous, or even osseous tissue. Kicord has laid down the law 
that suppuration never takes place in uncomplicated syphilitic orchi- 
tis, and has shown that many supposed cases to the contrary were 
really instances of tubercular disease of the testis or gummy tumors 
of the cellular tissue of the scrotum. This law has generally been 
admitted as correct, and has not until recently been called in ques- 
tion ; but Eollet 1 has reported an unquestionable instance of this 
disease in which the substance of the testicle protruded through an 
ulceration of the scrotum, and the tunicas vaginalis and albuginea, 
giving rise to the condition known as fungus of the testicle ; and 
also quotes a similar case, witnessed by himself, from Jarjavay, and 
refers to another described by Curling. 2 Victor de Meric 3 has 
reported still another instance of fungus of the testicle dependent 
upon syphilis ; and I would also call the reader's attention to the 
case of orchitis, attended by suppuration, in an infant affected with 

' Annuaire de la Syphilis, annee 1848, p. 90. 

2 On the Testis, 2d ed., p. 277. 

3 London Lancet, Am. ed., May, 1859. 



638 SYPHILITIC OECHITIS. 

hereditary syphilis, which has been reported upon page 465. It 
would appear, therefore, that Kicord's law is not without exception. 

Diagnosis. — Syphilitic orchitis may be confounded with gonor- 
rhceal epididymitis, with cancer, tubercular disease of the testis, or 
chronic orchitis. 

Gonorrhoeal inflammation of the testis is an acute disease, at- 
tended with severe pain, difficulty of motion, redness, heat, and 
tension of the scrotum; chiefly attacking the epididymis; often 
complicated with inflammation of the vas deferens; preceded or 
accompanied by a discharge from the urethra; and yielding to 
simple treatment. The induration left by an acute attack of 
swelled testicle may be recognized by the previous history of the 
case and by being limited to the epididymis. 

In cancer of the testicle, which is generally of the encephaloid 
variety, the pain is slight at the commencement, but increases with 
the progress of the disease and becomes very severe and lancina- 
ting ; the tumor is very irregular, grows with great rapidity, and 
often attains an immense size; and the cord and neighboring 
ganglia are frequently involved. " If you remove a cancerous tes- 
ticle, the disease almost always returns in the cord ; in a second 
attack of syphilitic orchitis, the opposite testicle is affected." 1 

Tubercular disease of the testis occurs about the age of puberty 
rather than in adult life, and in subjects presenting evidences of a 
strumous diathesis. The adventitious deposit first takes place in 
the epididymis, or in the centre and not in the external portions of 
the testis as in syphilitic orchitis ; as the disease progresses, slight 
protuberances may be formed upon the surface as in the last men- 
tioned disease, but they soon contract adhesions with the tunica 
vaginalis and scrotum, suppurate and ulcerate. Moreover, evi- 
dences of tubercular deposit may often be detected in the vesiculae 
seminales by examination with the finger per anum, or in the cord 
and inguinal ganglia. 

Great diversity of opinion exists, especially between English and 
French surgeons, relative to the frequency, nature, and symptoms 
of chronic orchitis. Mr. Curling, who may be taken as the repre- 
sentative of English views, regards this affection as quite common, 
and dependent upon a deposit, generally in circumscribed masses, 

1 Dupuytren, Leons Orales de Clinique Chirurgicale, 2d ed., t. iv. p. 236. 



TREATMENT. 639 

of a peculiar yellow homogeneous substance in the body of the 
testicle, which frequently terminates in suppuration and benign 
fungus of the testis. Among the French, Nelaton maintains, justly, 
I think, that this description applies to true tubercular testis, and 
that Curling has also included under the head of chronic orchitis 
many cases of syphilitic albuginitis. He believes, with the gen- 
erality of French surgeons, that chronic orchitis is an exceedingly 
rare affection ; that it is due to plastic inflammatory infiltration, 
bearing no resemblance to tubercle, in the substance of the epididy- 
mis and body of the testicle, not circumscribed in well-defined 
masses, often very persistent, but capable of absorption without 
suppuration ; that it often originates in irritation about the deeper 
portions of the urethra, and sometimes gives rise to a very peculiar 
condition of the sperm, which is of a reddish color, resembling 
thin currant jelly. 1 

It is unnecessary to enter more minutely into the details of the 
differential diagnosis between syphilitic orchitis and the above 
mentioned diseases. If attention be paid to their prominent fea- 
tures as now described, especially when assisted by a knowledge 
of the history of the case and a careful search for coexisting syphi- 
litic symptoms or traces of their previous existence, the surgeon 
will not often be left in doubt. If any uncertainty exist, the pa- 
tient should always have the benefit of a trial of specific remedies 
before resorting to operative procedures. 

Treatment. — In the treatment of this disease, Eicord relies almost 
exclusively upon iodide of potassium, administered in doses of from 
five to thirty grains three times a day. It would appear that Eicord 
is here somewhat inconsistent with his own doctrines, since he else- 
where recommends a mixed treatment consisting both of iodide of 
potassium and mercury in the transition symptoms of syphilis, 
among which he ranks syphilitic orchitis. In my own practice, I 
have been dissatisfied with the iodide of potassium alone and have 
obtained much more favorable results from its combination with 
mercury. For instance, in a case recently under my care, the pa- 
tient had been taking ten grains of the iodide three times a day 
during two months for a tubercular syphilitic eruption, when my 
attention was first called to the affection of the testicle, which had 

1 Gaz. des Hop., No. 14, 1857. 



640 SYPHILITIC ORCHITIS. 

either appeared or certainly had not improved during the treat- 
ment. The dose of the remedy was gradually increased to twenty 
grains three times a day without affecting the orchitis, which 
speedily improved after substituting half a grain of the protiodide 
of mercury for the iodide of potassium taken at noon, and con- 
tinuing the latter remedy morning and night. In many cases, and 
especially in broken-down constitutions, it is better to employ 
mercurial inunction upon the inner portions of the thighs and 
axillae together with the iodide of potassium and tonics internally. 
Diday expresses himself very decidedly in favor of a mixed 
treatment. He says : " The treatment of this affection is of impor- 
tance both as an element of diagnosis and as a means of recovery. 
I do not share the exclusive confidence of certain specialists in 
the employment of iodide of potassium alone in this disease. I 
grant it is an excellent remedy, and perhaps the best, if only one 
is to be used ; but some credit, I think, should be reserved for mer- 
cury. Can we forget or deny the success which was obtained by 
Sir Astley Cooper and Dupuytren at a time when this metal alone 
had the responsibility as well as the honor of curing ? And does 
not syphilitic chronology, in assigning to this lesion a position mid- 
way between secondary and tertiary symptoms, indicate that the 
most successful treatment will be one of a mixed character ? In 
my own practice, experience has confirmed these anticipations. I 
confess that if it were necessary to choose between mercury and 
iodine, I would give up the former rather than the latter ; but I am 
very positive that their simultaneous use is often indispensable. 
The association of these remedies is almost always sufficient, but 
careful observation of recent cases occurring in my practice would 
seem to warrant the conclusion that mercury acts better at the com- 
mencement of treatment and iodine afterwards ; that the former 
possesses a decided superiority during two or three weeks, after 
which time it is powerless compared with the efficacy which the 
latter now acquires. If I were asked for an explanation of this 
peculiarity, the truth of which has been demonstrated by experi- 
ence, I should say that mercury, by virtue of its anti-plastic pro- 
perty, is of service in rendering soluble the intertubular deposit so 
that it is more readily absorbed ; and that iodine afterwards comes 
in to better advantage as a true specific, with its anti- syphilitic and 
anti-tertiary property, and stimulates the process of absorption." 1 

1 Nouvelles Doctrines sur la Syphilis, p. 499. 



TREATMENT. 641 

The experience of the surgeons of the New York Hospital, as 
reported by my friend Dr. Thos. M. Markoe, 1 has been similar, and 
decidedly against the exclusive employment of iodide of potassium. 

Local treatment is of secondary importance, and, in most in- 
stances, may be entirely dispensed with, except that the testicles 
should be relieved of their own weight by a suspensory bandage. 
Judging from the case reported by Eollet, even a fungoid growth 
of the testicle projecting through an ulceration of the scrotum, 
will disappear and cicatrization take place under the use of con- 
stitutional remedies alone. The local treatment commonly recom- 
mended, and which perhaps in a few cases may be employed with 
advantage, consists in daily mercurial inunction upon the scrotum, 
or compression by means of straps of adhesive plaster as in swelled 
testicle from gonorrhoea. The effusion into the tunica vaginalis is 
in most cases soon absorbed under general treatment, but if exces- 
sive, may be evacuated by means of a lancet or broad needle. The 
danger of wounding the swollen testis is too great to admit of the 
use of a trocar as in the ordinary method of tapping for hydrocele. 

1 New York Medical Times, Marcli, 1855, p. 204. 



41 



642 AFFECTIONS OF THE MUSCLES AND TENDONS. 



CHAPTER XV. 

SYPHILITIC AFFECTIONS OF THE MUSCLES AND 

TENDONS. 

Syphilitic affections of the muscles, although noticed by As- 
true, 1 attracted but little attention until investigated during the 
present century, more especially by Boyer, 2 Eicord, 3 Bouisson, 4 and 
ISTotta. 5 These affections may be enumerated as muscular pains, 
muscular contractions, and muscular gummata or tumors. 

Muscular Pains. — Muscular pains dependent upon syphilis 
have already been described 6 as frequently accompanying the 
earliest outbreak of general symptoms ; affecting by preference the 
neighborhood of the joints ; often involving the fibrous as well as 
the muscular tissues ; fleeting and changing in their character ; re- 
lieved by pressure; and, in most cases, unattended by swelling, 
heat, or redness. In the tertiary period of syphilis, also, patients 
often complain of pains in the extremities, but these are depend- 
ent upon changes in the periosteum or bones, or upon deposits of 
syphilitic tubercle in the muscles, and are therefore to be regarded 
as merely symptomatic of lesions described in this and other 
chapters. 

Muscular Contraction. — This singular effect of constitutional 
syphilis consists in a diminution in the length of one or more 
muscles, interfering with motion, but without the existence of other 

1 A Treatise of Venereal Diseases, etc., translated from the Latin, London, 1754, 
vol. ii. p. 15. 

2 Traite pratique de la Syphilis, Paris, 1836. 

3 Notes to Hunter, 2d Am. ed., 1859, p. 458. 

4 Gaz. Med. de Pnris, 1846, p 211. 

5 Mem. sur la Retraction Muscul. Sjph., Arch. Gen. de Med., Dec. 1850, 4e 
serie, t. xxiv. p. 413. 

« See p. 547. 



MUSCULAR CONTRACTION. 643 

changes appreciable upon external examination. The muscles 
most frequently affected are the flexors of the upper extremity, 
and especially the biceps. Notta met with six cases, in two of 
which the disease was confined to the biceps ; in two others, to the 
biceps and supinator longus; and in the remaining case to the 
flexors of the fingers. The biceps has been affected with the same 
frequency in the cases reported by other observers. 

The contraction comes on insidiously, and the first symptom 
noticed by the patient is an inability to extend the limb. On ex- 
amining the affected muscle, no change is perceptible either in its 
size or texture ; its power of contraction is normal ; and there is 
simply a diminution in length, as shown by its tension when the 
limb is forcibly extended. In neither of Notta's six cases was the 
fleshy portion of the muscle sensitive to pressure ; but in five, pain 
was excited by pressing upon one or both of the tendinous inser- 
tions, and by forced extension. The contraction increases, slowly 
in most cases, but rapidly in some, up to a certain point, when it 
remains stationary. In five cases in which the biceps was affected, 
the angle formed by the arm and forearm, when the latter was ex- 
tended to the utmost, measured 160°, 135°, 135°, 130°, and 90°, 
respectively. In another case, the ring and little fingers were com- 
pletely flexed upon the palm of the hand. 

Under the name of "chronic syphilitic tetanus," Deville 1 has re- 
ported a case in which a large number of muscles were involved, 
and death ensued from contraction of the muscles of the pharynx, 
which was impassable to a probang. Notta coincides with Deville 
in regarding the disease as syphilitic. 

In none of JSTotta's cases had the patients ever suffered from 
rheumatism, which, therefore, could have had no part in producing 
the muscular contraction ; but all presented unquestionable syphi- 
litic symptoms, which, in three, belonged to the tertiary; in two to 
the secondary ; and in one to both the secondary and tertiary pe- 
riods. So far, therefore, as it is admissible to judge from so small 
a range of statistics, it may be concluded that muscular contrac- 
tion, like syphilitic orchitis, belongs to the period of transition 
intervening between pure secondary and tertiary manifestations. 

The treatment of this affection consists in the combined adminis- 
tration of mercurials and the iodide of potassium. By these means 

1 Bulletin de la Soc. Anatomique, 1845, p. 276. 



644 AFFECTIONS OF THE MUSCLES AND TENDONS. 

Kotta succeeded in effecting a perfect cure in four cases ; in a fifth 
the relief was only partial ; and in the sixth treatment had no effect 
whatever. As is true of other syphilitic symptoms, the disease is 
likely to return if treatment be suspended too soon. 

The pathology of syphilitic contraction of the muscles is obscure. 
Yirchow ascribes it to "callous degeneration of the muscular tissue ; 
an alteration analogous to that produced by rheumatic inflammation, 
either simple or traumatic. In the interspaces between the muscu- 
lar fasciculi, a conjunctive tissue is developed, which hardens and 
produces atrophy, and finally the destruction, of the primitive 
muscular fibrils." 1 

Muscular Tumors. — Our knowledge of syphilitic tumors of 
the muscles, tendons, and aponeuroses is due in a great measure to 
the labors of M. Bouisson, late Prof, of Surgery at Montpellier. 
These tumors consist of the same gummy material which has been 
described in a previous portion of this work. Indeed we have 
already referred to deposits of this nature in the muscles when 
speaking of syphilitic affections of the mouth and air passages ; 
since tubercles of the tongue are frequently seated in the muscular 
as well as in the cellular tissue ; and many of the sloughing ulcers 
of the velum palati, pharynx and larynx, commence as gummy 
tumors of the neighboring muscles, the mucous membrane being 
involved secondarily. Mention has also been made of similar 
tumors in the lips, which have sometimes been mistaken for epi- 
thelial cancer. In addition to the muscles of the regions here 
mentioned, gummy tumors have been met with in the glutaeus 
maximus, trapezius, sterno-cleido-mastoideus, vastus externus, pec- 
tor alis major, and some others ; and in the walls of the heart by 
Eicord, 2 Lebert, 3 and Yirchow. 4 

" Syphilitic tumors of the tendons appear to depend upon circum- 
scribed hypertrophy of the normal fibrous tissue, together with an 
effusion of serous and plastic material. They are the seat of more 
or less pain, which is increased by the action of the corresponding 
muscle. If the tendon be examined after death, it is found to have 
preserved its normal color or to be but very slightly injected ; but 

1 La Syphilis Constitutiormelle, p. 105. 

2 Iconographie, PI. XXIX. 

3 Traite d'Anatomie Pathologique, t. i. PL LXVIIL, Fig. 5. 

4 La Syphilis Constitutiormelle, p. 108. 



MUSCULAK TUMOES. 645 

it is swollen either from thickening of its fibres, or the deposition 
of an albuminous and semi-solid material within its substance. In 
old cases not terminating in suppuration, ossification may take 
place and involve the whole extent of the tendon, as in one instance 
I have met with in the psoas parvus ; in other cases it is limited to 
the part of the tendon first affected, and gives rise to a kind of 
sesamoid bone. 

"Syphilitic tumors of the tendons are sometimes situated near 
their surface and sometimes at their centre. The former are the 
more common. In this case the swelling is more perceptible and 
forms an abrupt projection in the course of the tendon ; and if 
suppuration takes place, the continuity of the fibrous cord is re- 
spected. But the disease may be limited to the central portion, in 
which case the normal fibres of the tendon are separated by the 
adventitious deposit, and the tumor assumes an ovoid or fusiform 
shape." 

Of syphilitic tumors in the muscles Bouisson says : "It is difficult 
to determine whether the earliest changes take place in the muscu- 
lar fibrils or in the intervening cellular tissue ; although analogy 
would lead us to believe that it is the fibro-cellular element connect- 
ing the fleshy fibres or serving as their sheath, which is first in- 
volved. But in advanced cases — no matter what the mode of 
termination, whether by suppuration or induration — all the ana- 
tomical elements appear to be affected; and, according to the pro- 
gress of the morbid action, the muscular fibres are either surrounded 
by a material of new formation or are softened and destroyed, or, 
again, are transformed into indurated, sub-cartilaginous or even 
osseous tissue. Such at least are the different stages I have met 
with in these tumors. 

" In the first stage, the muscle is the seat of a local and circum- 
scribed swelling, of greater consistency than oedema. Upon a cut 
surface of the diseased tissue we can recognize decolorized muscu- 
lar fasciculi in the midst of a plastic effusion of a grayish color. 

" In the second stage, the adventitious deposit softens, and, if the 
attendant inflammation continues of a chronic character, is trans- 
formed into a viscid, stringy liquid, resembling a solution of gum. 
If, on the contrary, acute inflammation sets in, or if the tumor has 
been attended from the outset with constant pain and an increase 
of temperature, pus is formed in the centre of the muscle, the 
fibres are softened and destroyed, and more or less disorganization 



64:6 AFFECTIONS OF THE MUSCLES AND TENDONS. 

takes place. I suspect that many intra-pelvic abscesses, and many 
cases of destructive inflammation of the psoas and iliacus muscle 
are really syphilitic phlegmasia} of the muscles of this region. I 
have frequently observed complications of this kind in syphilitic 
subjects; and I recently called the attention of my students to a 
patient at the hospital, who was seized with chronic inflammation 
of the psoas and iliacus muscles on the left side. A tumor of con- 
siderable size formed in the pelvis, and pointed near Poupart's 
ligament. On being opened an enormous quantity of pus escaped. 
The patient was subjected to specific treatment, and completely 
recovered. 

" In the third stage, those syphilitic tumors of the muscles which 
do not suppurate, become indurated. Like periostoses, they pass 
through successive stages of organization, and from being firm, 
become sub-cartilaginous, cartilaginous, and osseous. This final 
•transformation, from its peculiarity and persistency, has especially 
attracted the attention of pathologists. I have seen a very remark- 
able example of it in the museum of the Faculty of Medicine at 
Strasbourg — an osseous mass of very considerable size developed 
in the substance of the quadratus femoris. Ossifications of the 
muscles and their tendons have frequently been observed in syphi- 
litic persons with exostoses on various parts of the body. In the 
collection of my colleague, Prof. Dubrueil, is the skeleton of an 
Arab who was affected with syphilis, and in whom, besides nu- 
merous exostoses, there was ossification of a large number of mus- 
cles at the points of their insertion." 1 

These tumors vary in size from that of a filbert to an orange. 
They are most easily detected when the muscle is relaxed, and 
their independence of the subjacent bone can then be best estab- 
lished. They excite little or no pain unless the muscle be put 
upon the stretch, and their chief inconvenience is due to their inter- 
ference with motion. They are almost always accompanied by 
other syphilitic manifestations, as nodes, exostoses, tubercles of the 
cellular tissue, or ulcerations of the fauces ; and their treatment is 
that of the advanced stages of the disease, viz., by means of the 
iodide of potassium and tonics, either associated with, or followed 
by, mercurials. 

1 Bouisson, op. cit. 



AFFECTIONS OF THE NERVOUS SYSTEM. 647 



CHAPTER XVI. 

SYPHILITIC AFFECTIONS OF THE NERVOUS 

SYSTEM. 

Among the affections of the nervous system, which, with greater 
or less probability, have been ascribed to syphilis, are the various 
forms of paralysis, apoplexy, epilepsy, mental derangement, dis- 
orders of sensibility, defective memory and intelligence, and the 
neuralgias. These affections may proceed — 

A. From caries, necrosis, or exostosis of the bones of the head or 
spinal column, involving the nervous centres, or the nerves them- 
selves secondarily. 

B. From lesions of the meninges of the brain and medullary 
canal; the most frequent of which are gummy tumors springing 
from the dura mater, and encroaching upon the cerebrum, cerebel- 
lum, or spinal marrow. 

C From gummy tumors developed in the substance of the brain, 
or in the course of the cranial nerves. 

D. In some instances, when post-mortem examination reveals no 
organic lesions to account for the nervous symptoms, but in which 
it is probable that such previously existed, but have since disap- 
peared either spontaneously, or, more frequently, as the effect of 
treatment. Ricord 1 reports a case of hemiplegia and mental de- 
rangement in a syphilitic subject, at whose post-mortem nothing 
abnormal was found in the brain or bones of the head, and similar 
instances are mentioned by other observers. 

Syphilitic affections of the nervous system present no pathogno- 
monic symptoms by which their specific character may be recog- 
nized ; and, except in those instances in which manifest lesions of 
the bones of the skull, face, or spine, clearly indicate the etiology 
of the disease, the diagnosis can only be established by the history 

1 Iconographie, PI. XXXIX. 



648 AFFECTIONS OF THE NERVOUS SYSTEM. 

of the case, the concomitant symptoms, and the effect of treat- 
ment. 1 

The two following cases of syphilitic epilepsy have occurred in 
my own practice. 

Case 1. Mr H., aet. 36, applied to me October 22, 1856, for a super- 
ficial erosion, with slightly indurated base upon the internal surface of the 
prepuce, and a pleiad of indurated ganglia in each groin. He was told 
that he had constitutional syphilis, and was immediately put upon the use 
of mercurials, under which the sore speedily healed, and the glands lost 
much of their hardness. 

Although the mouth was kept tender for several weeks, and treatment 
was continued until the first of April, yet a papular eruption made its ap- 
pearance May 21, accompanied by mucous patches on the tonsils, and 
pustules upon the scalp and beneath the whiskers. Treatment was again 
resumed, but as soon as his symptoms had been dissipated, Mr. H. became 
irregular in taking his medicine, and had another relapse the following 
August. He now became convinced of the necessity of pursuing treat- 
ment faithfully for a long period, and expressed himself willing to follow 
any directions which I should give him. 

I determined to pursue the course recommended by Ricord, 2 and give 
my patient mercurials for six months, keeping him constantly upon the 
verge of salivation, and afterwards iodide of potassium in full doses for 
three months. Mr. H. faithfully obeyed my directions, and maintained 
his general health and strength to a remarkable degree under the depress- 
ing influence of mercurials, which were continued in as full doses as could 
be borne without producing salivation until the middle of February. 
The iodide of potassium was now commenced, and gradually increased 
from fifteen to forty-five grains a day, but was suspended about the middle 
of April, a month before the appointed time; however, as the mercurial 
treatment had been pursued so thoroughly, this was regarded as of slight 
importance. 

On May 2d of the same year (1858), only a fortnight after suspending 
this active course of treatment, Mr. H. again applied to me, complaining 
of frontal headache, which was not, so far as I could learn, nocturnal in 

1 When the reader is informed that M. Lagneau, fils, has written a closely-printed 
volume of 528 pages, octavo, upon syphilitic affections of the nervous system, he 
will appreciate the impossibility of my doing justice to this subject within the 
limits of the present work. For farther details, I would refer to the work in ques- 
tion, which comprises all that is now known upon the subject, and includes most 
of the cases published by various authors. 

2 See page 520. 



AFFECTIONS OF THE NERVOUS SYSTEM. 649 

its character, and which I attributed to excessive attention to his busi- 
ness, and late hours. His bowels were also quite costive. 

On the evening of May 5th, Mr. H. assisted in putting out a fire at the 
house of a neighbor, and on the following day, while at his office, was 
suddenly seized with an epileptic fit, which was followed by five others 
before night. I saw him in several of them, and found that they pre- 
sented the ordinary characters of epilepsy, viz., loss of consciousness, con- 
vulsive action, foaming at the mouth, biting the tongue, etc., followed by 
stupor for a short period afterwards. 

He recovered sufficiently from this attack in three or four days to re- 
sume his business, and was feeling quite well again, with the exception 
of some continuance of the headache, and a tendency to constipation, when 
on the 28th of the same month he sprained his ankle, which obliged him 
to keep his bed ; and on the following day (29th) he was again seized with 
epilepsy, and had, as before, six fits before night. He did not recover 
from this as from his previous attack, but was left in an exceedingly ex- 
cited, and, at times, almost maniacal condition. For a few moments he 
would converse rationally and connectedly, and then suddenly cry out at 
the top of his voice, and talk in the most incoherent manner; his memory 
also left him in a great measure, and, at times, he did not appear to recog- 
nize his friends around him. It should be here stated that Mr. H. was a 
man of abstemious habits, and, although of a naturally nervous tempera- 
ment, had never before suffered from any cerebral affection. 

The question now arose in my mind whether his symptoms were due to 
his syphilitic taint, but was answered in the negative, on the ground that 
he had but just completed so thorough a course of anti-syphilitic treat- 
ment; and I feared in his present condition to resort again to mercurials. 
I, therefore, directed him to be kept quiet and away from business, and 
to take a daily ride in a carriage; introduced a seton in the back of his 
neck; and prescribed valerianate of zinc, combined with extract of hyos- 
cyamus internally, together with cathartics, when required. This treat- 
ment, however, had but little effect ; the seton gave him so much annoy- 
ance, and appeared to increase his irritability to such a degree, that I was 
compelled to withdraw it; his fits did not return, although he was several 
times threatened with them ; but his almost insane condition continued 
with but little amelioration until June 17th, when I sent him into the 
country for a change of air and scene. Here he somewhat improved, 
although almost imperceptibly ; he was still troubled with headache, and 
was at times very excitable. 

About the middle of August, an eruption of syphilitic psoriasis appeared 
upon his legs and body, and led me at once to doubt the correctness of 
my previous conclusion as to the nature of his complaint, and to regard 
it as syphilitic. I immediately commenced the use of protiodide of mer- 



650 AFFECTIONS OF THE NEEVOUS SYSTEM. 

cury and iodide of potassium, under which the improvement in his cere- 
bral symptoms was as gratifying as it was astonishing, and my patient 
returned to his business before the end of August, with his mental faculties 
completely restored. 

Since that time he has been actively engaged in his profession, and 
constantly in good health, except on two occasions, when he has had a 
slight return of his syphilitic eruption, which is always preceded by mental 
depression and nervous excitability. Mercury acts like a charm under 
these circumstances, dissipates the eruption, and restores his health and 
spirits. 

This case is, in many respects, a very peculiar one. The decided benefit 
which has always been derived from mercurials, and yet the frequent re- 
lapses which have taken place, are quite unusual. Yarious preparations 
of mercury, and different modes of its administration, among others mer- 
curial fumigation, have been tried without affording permanent relief. 
The pathology of the nervous affection is also obscure, since the symp- 
toms have always been those of the secondary stage of syphilis, and not 
such as would indicate lesions of the fibrous and osseous tissues. The 
facility with which they have yielded to remedies would lead one to sus- 
pect effusion within the ventricles, or at the base of the brain. It should 
be remarked that the urine has been repeatedly examined and found to 
be normal ; and there has been no evidence of disease in the kidneys or 
other organs. 

Case 2. Mr. W., aet. 38, a gentleman by birth, and a man of fine con- 
stitution, but sadly addicted to drink, applied to me June 14, 1860, for 
an erythematous eruption upon the abdomen, and mucous patches upon 
the tongue, the result of contagion three months before. He still bore 
an indurated mass in the site of the chancre in the furrow at the base of 
the glans, and the inguinal glands were also indurated. The eruption 
disappeared within a fortnight under the use of the protiodide of mercury, 
and I urged him to continue treatment for some time longer. This he 
promised to do, but I lost sight of him, and afterwards learned that he 
gave up taking his medicine within a few days after his last visit. 

I next saw him at his house, October 14th, after he had been on a debauch 
for three weeks, during which time he had not been home, and had slept 
in a bar-room. He was now one of the most disgusting and yet pitiable 
objects I ever saw. His hair, which was naturally black when I last saw 
him, had turned to an iron gray; his head was covered with a pustulo- 
crustaceous eruption, arranged in circles, or segments of circles ; there 
was a large patch of the same eruption over the sternum; the post-cervical 
glands were very much engorged; the internal surface of his lower lip 
was covered with opaline patches, and his voice indicated ulceration of the 



AFFECTIONS OF THE NEEVOUS SYSTEM. 651 

fauces; the palms of his hands presented copper-colored rings of elevated 
and scaly integument; all of his finger nails without exception were ulce- 
rated around their bases ; and the buttocks and upper and inner portions 
of his thighs were profusely scattered over with condylomata, the secre- 
tion from which filled the room with its offensive odor. 

During this and the two following days, my patient had six or eight 
epileptiform seizures, characterized by loss of consciousness, convulsive 
action, and foaming at the mouth ; in the intervals of which he was per- 
fectly rational, and exhibited no more nervous agitation than is commonly 
observed after a debauch. 

The treatment adopted consisted in mercurial inunction externally, and 
the internal administration of quinine and sedatives, together with a nou- 
rishing diet; and by the first of December, Mr. W. left for the South, 
entirely relieved of his syphilitic symptoms. 



652 AFFECTIONS OF THE PEEIOSTEUM AND BONES. 



CHAPTER XVII. 

SYPHILITIC AFFECTIONS OF THE PEEIOSTEUM 

AND BONES. 

These affections are among the latest manifestations of the syphi- 
litic diathesis, and may be regarded as types of tertiary syphilis. 
They do not necessarily occur in every case of syphilis, even if left 
to itself without treatment ; since the disease often wears itself out 
before arriving at the tertiary period ; while, still more frequently, 
it is arrested by appropriate remedies administered during the pri- 
mary or secondary stage. The idea, which is sometimes advanced, 
that these affections are due to mercury, even when judiciously 
employed, is entirely without foundation. This mineral is gener- 
ally necessary in conjunction with the iodide of potassium to effect 
their permanent removal, and can never favor the evolution of 
tertiary syphilis, unless pushed to the detriment of the general 
health. 

In the time of their development tertiary follow secondary lesions, 
or coincide with the later forms of the latter. The absolute inter- 
val which has elapsed since contagion, at the time of their appear- 
ance, varies very much in different cases, and chiefly depends upon 
individual peculiarities, the mode of life of the patient, and the 
treatment to which he has been subjected. It often amounts to 
many years, and, according to Kicord's rule, which is undoubtedly 
correct, is rarely, if ever, less than six months. 

"We meet with some instances in which syphilis appears to skip 
over its secondary, and manifest itself only in its primary and ter- 
tiary forms. A man has an infecting chancre, and after several 
years of apparent health is attacked with tertiary symptoms, as, 
for instance, osteocopic pains, ostitis, or tubercles of the deep cellu- 
lar tissue. In such cases, either the patient was subjected to mer- 
curial treatment for his primary sore, which has prevented secon- 
dary, but has not been sufficient to avert tertiary manifestations; 



OSTEOCOPIC PAINS. 653 

or lie has had secondary symptoms of so slight a character as not 
to attract attention. As I have shown at length in a previous 
chapter, the general symptoms of syphilis, in the absence of specific 
treatment, always appear within six, and generally within three 
months after infection. 

In many cases the morbid processes which syphilis sets up in the 
periosteum and bones, appear to be the same as those induced by 
other causes. Thus, we find inflammation of the periosteum and of 
the siibjacent layer of bone, terminating in an effusion of sero- 
albuminous or purulent matter — in other words, forming an ab- 
scess, which finally opens externally through thinning and ulcera- 
tion of the integument. In like manner, syphilis often gives rise 
to ostitis, terminating in suppuration, caries, and necrosis, which 
cannot be distinguished from the effects of non-specific causes of 
inflammation. In many instances, however, syphilitic affections of 
these tissues exhibit the same marked tendency to the effusion of 
plastic material, which has been noticed when speaking of tertiary 
ulcerations of the air passages. Thus the adventitious deposit of 
nodes is often transformed into true bony tissue (epiphysary exos- 
toses); and syphilitic ostitis frequently gives rise to outgrowths 
springing from the bone itself (parenchymatous exostosis) ; or it 
may result in general hypertrophy (hyperostosis). Again, when 
attacking the periosteum and bones, syphilis sometimes causes a 
deposition of the same material, known as syphilitic tubercle, which 
is found in the gummata of other regions. Whether these various 
changes are to be regarded as distinct, or as stages of one and the 
same process, cannot, in the present state of our knowledge, be fully 
determined. 

Osteocopic Pains. — The pains in the bones, belonging to ter- 
tiary syphilis, differ from those observed in connection with early 
secondary symptoms, in being confined to certain regions, and in 
not changing their locality like the latter. Their favorite seat is 
in those bones which approach nearest the surface, as the tibia, 
ulna, clavicle, sternum, and cranium; but no portion of the skele- 
ton is exempt from them. In most cases they are increased, but 
in others are uninfluenced by pressure. A striking peculiarity of 
these pains is their marked nocturnal character. They are gener- 
ally absent or are scarcely felt during the day, but return at night 
with great severity after the patient retires to bed, and only abate 



654 AFFECTIONS OF THE PERIOSTEUM AND BONES. 

towards morning. This nocturnal exacerbation is attributed to the 
warmth of the bedclothes by Kicord, who states that in bakers, 
who are obliged by their occupation to turn day into night, the 
pains are chiefly diurnal. This explanation, however, does not 
appear to hold good in all cases, for in some they return at a cer- 
tain hour in the evening, whether the patient has or has not retired ; 
and, in a few instances, they are equally as severe during the day 
as at night. In most cases tertiary osteocopic pains are merely 
symptomatic of commencing changes in the periosteum or bones, 
which, in the absence of appropriate treatment, are usually mani- 
fest within a few months. In other instances, however, they per- 
sist for a long period without the appearance of any appreciable 
organic lesion; although, even then, it may be questioned whether 
the deeper portions of the bones, or the lining membrane of the 
medullary canal, be not affected. 

Osteocopic pains yield with great facility to the internal admin- 
istration of iodide of potassium, but are very prone to relapse. In 
most cases, their permanent removal can only be effected by care- 
ful attention to the general health and the judicious employment 
of mercurials. Patients have frequently been under my care, who 
for years have been obliged to resort to iodide of potassium every 
few months for the relief of tertiary pains, which have ceased to 
return after a mercurial course, administered either by the mouth, 
by fumigation, or inunction. Mercurial inunction is especially 
adapted to these cases. 

Nodes. — In the formation of nodes, inflammation of the super- 
ficial portion of the subjacent bone, as well as of the periosteum 
itself, doubtless has a share; although the adventitious deposit 
which constitutes the swelling is chiefly effused from the latter 
tissue. These tumors exhibit a preference for those regions already 
mentioned as the favorite seat of osteocopic pains. They are most 
frequent upon the internal surface of the tibia and upon the bones 
of the head; but are also seen upon the clavicle, sternum, ribs, 
radius, ulna, etc., and similar changes may take place beneath the 
lining membrane of the medullary canal in the long bones, and 
between the dura mater and the bones of the skull. 

When seated upon the superficial bones, nodes appear as ill- 
defined tumors, adherent to the osseous tissue beneath, generally 
tender upon pressure, giving rise to severe nocturnal pain, and un- 



NODES. 655 

attended, at least at their commencement, by redness of the integu- 
ment which is movable over them, and only becomes involved, if 
at all, in the subsequent progress of the tumor. If an opportunity 
be offered to examine their internal structure, the periosteum is 
found to be injected and thickened by infiltration into its substance, 
and elevated above the bone by an effusion of fluid. In some cases, 
the effusion consists of pus, which after a time finds exit through 
ulceration of the integument and exposes the bone, which often 
becomes carious or exfoliates. 

In other instances, the effusion consists of a yellowish, gelatinous 
fluid, containing an abundance of fat-corpuscles as seen under the 
microscope, and inclosed in a loose network of cellular tissue. 
This variety, which generally undergoes resolution, resembles the 
gummy deposits which take place in the cellular tissue, in the mus- 
cles and many of the viscera, and has been denominated " gummy 
periostosis." Eicord 1 has reported and figured a case of perios- 
tosis upon the internal surface of the tibia, in which there was a 
deposit of gummy material in the corresponding portion of the 
medullary cavity of the bone and in the substance of the neigh- 
boring tibialis posticus muscle, together with simple hypertrophy 
of this part of the shaft of the tibia. 

In a third variety, which is the most common, the tumor is 
hard and firm ; the nocturnal pain is especially severe ; and the 
contained fluid, which is of a plastic character, acquires greater 
consistency and often gives rise to an exostosis, at first separated 
from the bone by cartilaginous tissue, which finally undergoes 
ossification. 

These epiphysary exostoses, as they are called, are generally of 
small size, sometimes thin and flat, and sometimes hemispherical 
or pedunculated. "At an early period of their existence, they 
consist of cellular tissue, containing a well-developed network of 
vessels. They acquire greater consistency with time, and finally 
present an eburnated texture. Arrived at this point, resolution is 
no longer possible ; the tumor remains stationary, and treatment 
has no other effect than to quiet the osteocopic pains. If resolu- 
tion be attained at an earlier period, their surface, which before 
was smooth, becomes irregular, indicating partial absorption. Some- 
times this absorption continues after the whole of the tumor has 

1 Iconographie, PI. XXVIII. bis. 



656 AFFECTIONS OF THE PEKIOSTEUM AND BONES. 

disappeared, so that local atrophy of the bone succeeds the exos 
tosis." ' In other instances, syphilitic exostosis is not preceded by 
periostosis, but is the result of ostitis terminating in hypertrophy 
of the normal bony tissue, in which case it is denominated paren- 
chymatous exostosis. 

An exostosis situated externally rarely occasions sufficient in- 
convenience or deformity to necessitate its removal by an operation 
unless under peculiar circumstances, as was the case with a violin- 
ist from whose metacarpal bone a tumor of this nature, which had 
interfered with the exercise of his profession, was removed by 
Eicord. 

But exostoses may also spring from the internal surface of the 
cranial bones and give rise to symptoms of the most serious char- 
acter, as convulsions and the various forms of paralysis. The 
frontal bone is by far the most frequently affected in this manner. 
Lagneau, in his able work 2 upon Syphilitic Affections of the Nervous 
System, has been able to collect but three cases of exostosis spring- 
ing from the parietal, and one from the sphenoid bone; he appears 
to have met with none in the occipital or temporal. These intra- 
cranial exostoses vary very much in size. Saltzman 3 reports a 
case in which the tumor occupied the internal surface of one of 
the parietal bones, commencing at two fingers' breadth from the 
sagittal suture and extending to the coronal suture in front and 
the temporal below ; the patient died with symptoms of apoplexy. 
Within the cranium 4 of Clermont-Ferrand, deposited in the Du- 
puytren Museum, are two exostoses, one of which is as large as an 
orange. In general, however, these tumors are much smaller, and 
often multiple. They also vary in density, some presenting a hard, 
eburnated texture, while others are cellular. Most of them spring- 
directly from the surface of the bone (parenchymatous exostoses) ; 
indeed, the existence of epiphysary exostoses within the cranium 
has been denied, but Tidal 5 gives a representation of a specimen 
in the Dupuytren Museum, in which the tumor is separated from 
the normal tissue by a distinct line of demarcation. 

1 Nelaton, Pathologie Cliirurgicale, t. ii. p. 16. 

2 Maladies Syphilitiques du Systeme Nerveux, par Gustave Lagneau, Fils. 
Paris, 1860, p. 45. 

3 Acta Phys. Med. Academise Ces.-Leop. Carol. Naturae Curiosorum Ephemerides ; 
Norimbergse, 1730, t. ii. p. 222, obs. 99 (as quoted by Lagneau, fils, op. cit., p. 361). 

4 Figured by Vidal, Pathologie Externe, 2e edition, t. iii. p. Ill, 1846. 
6 Op. cit., t. iii. p. 116. 



CARIES AND NECROSIS. 657 

Syphilitic exostosis of the vertebrae, either external or within 
the spinal canal, is rare; but Lagneau 1 has adduced several in- 
stances reported by Cloquet and Berard, Godelier, Piorry, and 
Minich. 

The treatment above recommended for osteocopic pains is 
equally applicable to nodes, which generally yield with great 
facility to iodide of potassium ; although a subsequent course of 
mercury is necessary to secure immunity for the future. The best 
local treatment is the one so highly extolled by Kicord, consisting in 
the repeated application of blisters which may be dressed with an 
ointment containing morphine or powdered opium. As a general 
rule, the swelling should not be opened, even if fluctuation be evi- 
dent, since resolution may almost always be obtained by the means 
indicated, and exposure of the bone is frequently followed by caries 
or necrosis of its superficial layer. . 

Caries and Necrosis. — Syphilitic caries and necrosis may 
arise — 

A. From ulceration of the soft parts in the neighborhood of the 
affected portions of bone. The ulcerative process involves the 
periosteum or perichondrium, and the bone or cartilage, deprived 
of its vascular supply, loses its vitality. This is the usual mode of 
origin of caries and necrosis of the hard palate, the bones of the 
nose, and the thyroid cartilage ; more rarely the superficial bones, 
as the clavicle, sternum, cranium, and the internal surface of the 
tibia, are similarly affected consecutively to ulceration of the in- 
tegument. 

B. From the suppuration and opening of nodes, whereby the 
bone is laid bare, and its vascular supply cut off. 

C. From suppurative inflammation of the osseous tissue inde- 
pendently of any affection of external parts. 

Caries and necrosis are not confined to any portion of the skele- 
ton, but are most frequent in the superficial bones. Although they 
generally attack the shafts of the long bones, yet they occasionally 
involve the neighborhood of the joints, where they cannot be dis- 
tinguished from the effects of scrofula except by the history of the 
case and the concomitant symptoms. 

Inflammation of the cranial bones resulting in caries and necro- 

1 Op. cit., p. 193. 

42 



658 AFFECTIONS OF THE PEKIOSTEUM AND BONES. 

sis usually commences in the external, but sometimes in the inter- 
nal table, and attacks the frontal far more frequently than either of 
the others. More or less of one of the tables may exfoliate, leaving 
the diploe and opposite layer intact. In a case observed by Du- 
puytren, 1 two-thirds of the internal table of the skull were necrosed ; 
and in another, reported by Petrequin, 2 the whole external table of 
the frontal bone exfoliated. More frequently, although the exter- 
nal table is involved to the greater extent, the diploe and internal 
table are perforated at one or more points, laying bare the dura 
mater, which, when the opening is large, may protrude externally, 
either preserving its normal character, or assuming a highly vas- 
cular and fungous appearance. 

When the disease commences in the internal table of the skull, 
the inflammatory products and portions of necrosed bone some- 
times find exit through perforation of the external parts ; or, in 
other instances, accumulate between the bone and dura mater, cause 
compression of the brain, or give rise to encephalo-meningitis and 
disorganization of the cerebral substance. Moreover, in nearly 
every case of syphilitic disease of the cranial bones, the dura mater, 
upon its internal or cerebral aspect, presents thin layers of fibri- 
nous or hemorrhagic deposit, which are easily detached from the 
surface. 3 

Virchow 4 states that necrosis produced by syphilis may be dis- 
tinguished from that due to other causes by the sequestrum, which 
is perforated with large holes and presents a worm-eaten appear- 
ance. "In syphilitic necrosis, the surface of the sequestrum is 
pierced with large holes, which unite internally and lead to the 
suspicion that they have been due to a deposition of gummy mate- 
rial; the surrounding tissue, whether necrosed or not, is often 
dense and eburnated, presenting a strong contrast to the above." 

The same author 5 has described among the syphilitic affections 
of the bones a form of caries without suppuration, to which he 
gives the name of " dry caries," or " inflammatory atrophy of the 
cortical substance of the bone," and which he believes is due to the 
compression exercised by deposits of gummy material. 

1 Clinique de l'Hotel Dieu ; Transactions Medicales, par MM. Forget et Sandras, 
Paris, 1832, t. x. p. 269 (quoted by Lagneau, op. cit., p. 403). 
' Gaz. Med. de Paris, 1836, t. iv. p. 643. 
8 Virchow, Syphilis Constitutionnelle, p. 50. 
* Op. cit., p. 49. 5 Op. cit., p. 37. 



CARIES AND NECROSIS. 659 

Extreme fragility of the bones has -often been noticed in persons 
affected with tertiary syphilis. A patient who was under my care 
a few years since for syphilitic necrosis of the bones of the head, 
fractured his thigh while simply turning in bed. Death ensued 
from exhaustion in the course of a few weeks, but no opportunity 
was offered for a post-mortem examination. 

It is unnecessary to repeat the directions already given for the 
constitutional treatment of tertiary syphilis, which includes that of 
syphilitic affections of the bones. In commencing ostitis, valuable 
assistance may be derived from the local application of blisters, 
which, as recommended by Ricord, may be dressed with mercurial 
ointment. 

" When suppuration or caries occurs, especially of the bones of 
the face which are so often necrosed in these cases, we should never 
fail to remove them as soon as they can be separated from the 
sound parts. "We must recollect that caries engenders caries ; that 
when the organic tissue of a bone has been destroyed by suppura- 
tion or has lost its vitality, it cannot be regenerated by any consti- 
tutional or local treatment whatsoever ; and that its debris should 
never be left to spontaneous evolution, since they are foreign 
bodies, maintaining and extending suppuration, which, by involv- 
ing important parts, may occasion the most serious symptoms, or 
even result in death." 1 

1 Ricord, Notes to Hunter, 2d Am. ed., 1859, p. 507. 



660 CONGENITAL SYPHILIS. 



CHAPTER XVIII. 

CONGENITAL SYPHILIS. 

Syphilis acquired during intra-uterine life is variously desig- 
nated as congenital, hereditary, or infantile. The first of these 
terms appears to me the most appropriate, since it includes those 
cases in which the disease is derived from one or both parents at 
the time of conception, and also those in which it is communicated 
to the foetus through the mother during gestation ; while it excludes 
those instances in which it is contracted during or after delivery, 
and in which syphilis pursues essentially the same course as in 
adults. 

Etiology. — Congenital syphilis may be derived from both 
parents; from the mother alone; from the father alone. In either 
case it is not necessary that the parent or parents, in whom the 
disease originates, should present syphilitic manifestations; the 
existence of the syphilitic diathesis is alone sufficient; and nu- 
merous cases have been reported of persons in whom the disease 
has been latent for many years, and who have yet had syphilitic 
children. 

When both parents are tainted with syphilis, and provided they 
have not been subjected to general treatment, the disease is almost 
certain to appear in their offspring. When one or both parents 
have received appropriate treatment, or when only one is affected 
with syphilis, the child may yet be born healthy. 

When the foetus is infected through the mother alone, the latter 
may have contracted the disease either before or after impregnation. 

Syphilis contracted by the mother prior to conception is sufficient 
to give rise to the disease in a child by a perfectly healthy father. 
Thus, a widow who has been infected by her first husband, may 
marry a healthy man and give birth to syphilitic children ; or a 
woman who has contracted the disease by nursing a syphilitic 



ETIOLOGY. 661 

infant, may be delivered of tainted offspring whose father is un- 
affected. 

An infant may also be born syphilitic in consequence of disease 
contracted by the mother subsequent to conception. Numerous 
instances of this kind are reported, and I have already mentioned 
one occurring in my own practice, in which the disease was com- 
municated by a husband to his wife as late as the end of the fifth 
month of gestation. 1 It is generally admitted, however, that the 
danger to the foetus is much less daring the latter months of preg- 
nancy than at an earlier period ; and Diday 2 concludes, from an 
analysis of eleven cases, that syphilis contracted by the mother after 
the completion of the seventh month has never produced the dis- 
ease in the foetus. As suggested by the same author, if this fact 
should be confirmed by farther observation, it would prove of con- 
siderable practical importance, in enabling us, when syphilis is 
contracted by a woman during the eighth or ninth month of preg- 
nancy, to dispense with mercurial treatment until after delivery; 
and also to intrust a child born under these circumstances to a wet 
nurse without danger of infection to the latter. 

Again, syphilis in the father may occasion the same disease in 
the foetus without previous infection of the mother. In most cases 
of hereditary syphilis, primarily due to disease in the father, we find 
that the mother has also been infected either before or during ges- 
tation ; but a number of instances have been reported in which the 
latter has continued perfectly healthy for a long period after deli- 
very, and in which the disease in the offspring must have been 
derived from the former alone. For a father to transmit syphilis 
to his child, it is not necessary that he should present upon his 
person, at the time of impregnation, the slightest syphilitic manifes- 
tation. He may have recently contracted an infecting chancre, and 
be passing through the period of incubation of secondary symptoms ; 
or the disease may have been subdued by treatment, and many 
years have subsequently been passed in apparent health. The ex- 
istence of the diathesis, even if it be latent, either in the father or 
mother, may engender syphilis in the offspring. 

It has been supposed by some, authors, if a man affected with 
syphilis has connection with a pregnant woman, that his semen 
may be absorbed, and conveyed directly to the foetus causing its 

1 See page 371. 2 De la Syphilis des Nouveau-nes, p. 48. 



662 CONGENITAL SYPHILIS. 

infection, without communicating the disease to the mother. So 
extraordinary an occurrence cannot be admitted unless sustained 
by indubitable evidence; and I am, therefore, surprised that it is 
regarded with favor by Diday, especially as he has been. able to 
adduce but one exceedingly lame fact, reported by Albers, in its 
support. The analogy drawn by Diday and Lawrence from the 
occurrence of smallpox in the foetus, while the mother remains ex- 
empt, is very far from conclusive, since the poison of variola is 
volatile, and is readily absorbed through the sound mucous mem- 
brane of the respiratory organs; whereas the syphilitic virus is 
communicated only by contact, and never, so far as we know, with- 
out causing ulceration at its point of entrance. Evidently, the 
transmission of disease, and of mental and physical characteristics, 
from the father to the ovum, at the time of impregnation, does not 
warrant our assuming, in the entire absence of evidence, the impro- 
bable supposition that the same may be communicated to the foetus, 
at any period of gestation, by a man who has connection with the 
mother. If this were so, the proof of paternity would, in many 
cases, be of an extremely doubtful character. 

Although syphilis acquired after leaving the womb of the mother 
is not properly included under the head of congenital or hereditary 
syphilis, yet a few remarks upon this subject will not be out of 
place at the present time. After its exit from the uterus, the infant 
is evidently exposed to the same sources of contagion as adults, 
with the exception of voluntary sexual congress. In its passage 
into the external world, its cutaneous surface is very thoroughly 
protected by a sebaceous coating which commonly prevents inocu- 
lation from any syphilitic lesion upon the genital organs of the 
mother ; and although contagion in this manner is by no means 
impossible, or even improbable, yet, according to Diday, no un- 
questionable instance has ever been reported. 

At a subsequent period, infants most frequently contract syphilis 
from wet-nurses, themselves affected with the disease, who bear 
either a primary or secondary lesion upon the breast. In most 
cases of contagion from a nurse to a nursling, the sore upon the 
breast of the former is an infecting chancre, accompanied by indu- 
ration of the axillary ganglia, and originally derived from a mucous 
patch upon the mouth of some child, whom she has previously 
nursed ; in other cases, the secretion of a secondary lesion is the 
source of contagion. The reader is referred to page 488 of the 



TRANSMISSIBILITY. 663 ' 

present work for a fuller account of the phenomena of secondary 
contagion. 

Although it is not improbable that the milk may have some 
influence in the transmission of syphilis to infants at the breast, 
yet no conclusive facts have hitherto been reported by which this 
method of contagion can be established beyond a doubt. 

Transmissibility. — "We have seen that an ovum, healthy at the 
time of conception, may become infected during the greater portion 
of the period of gestation in consequence of the mother contracting 
syphilis. This influence, as existing between mother and child, is 
mutual; and a foetus contaminated with syphilis by its father may 
communicate the same disease to a mother, who was unaffected at 
the time of impregnation. Infection of a mother through the me- 
dium of a foetus was, according to Mr. Hutchinson, first noticed by 
Gardien (Traite des Accouchements) in 1824, and is admitted by 
most recent writers upon venereal, among whom may be mentioned 
Eicord, Diclay, Depaul, Acton, Harvey, Tyler Smith, and Balfour; 
it is by no means, however, to be regarded as a necessary conse- 
quence of the contamination of the ovum by a diseased father ; and, 
as in thirteen cases reported by "Victor De Meric, 1 a mother may 
give birth to a syphilitic child, and yet never present the slightest 
evidence that she herself is affected. The contagiousness of secon- 
dary lesions, which is now established beyond question, will pro- 
bably explain many cases in which a wife becomes infected in the 
absence of primary sores in her husband, and which have hitherto 
been considered, especially by the advocates of Kicorcl's earlier 
views, as instances of the communication of the disease through the 
foetus. 

In consequence of the frequency of mucous patches upon the 
buccal mucous membrane and the intimate contact between the 
mouth and breast in the act of nursing, instances of the communi- 
cation of secondary syphilis by an infant affected with hereditary 
syphilis are far more numerous than those by adults. In France, 
where children are often sent to a wet-nurse in the rural districts, 
syphilis is thus not unfrequently conveyed to villages where it 
was previously unknown, and, spreading from one person to 
another, finally affects a large number of individuals. The fre- 

1 Lettsomian Lectures, p. 65. 



664 CONGENITAL SYPHILIS. 

quency of instances of this kind induced Diday, in his able work 
upon Infantile Syphilis, to admit that hereditary syphilis possesses 
a peculiar virulence and powers of contagion greater than those of 
acquired syphilis ; a distinction which he has abandoned since the 
contagiousness of secondary manifestations in general has been 
conclusively demonstrated. 

To the liability of contagion from the lesions of hereditary syphi- 
lis, there is an important exception which first attracted the attention 
of the acute mind of Abraham Colles, of Dublin ; it is this, that 
although the disease is frequently communicated by an infant to a 
wet-nurse, yet a mother has never been known to be infected from 
nursing her own offspring. This fact, singular as it may at first 
appear, is, in most cases, susceptible of ready explanation; it is, 
indeed, merely an exemplification of the "unicite" of the syphilitic 
diathesis ; for whenever the mother has already been contaminated, 
either directly by the father or indirectly through the foetus in utero, 
she is thereby protected from a second infection ; and even when 
she presents no evidence of a syphilitic taint, she must have been 
exposed to it during gestation, and her immunity is to be ascribed 
to a constitutional inaptitude to contract the disease; in other 
words, the mother has undergone before delivery the greatest 
amount of exposure to which the foetus can subject her, and which, 
if capable of infecting her system at all, has already done so before 
the birth of the child. 

Abortion. — Syphilis is so frequent a cause of the premature 
expulsion of the foetus, that repeated abortions form a valuable 
element of diagnosis in the investigation of suspected cases of this 
disease in married life. It has sometimes been supposed that the 
cause of the abortion in these cases was not a syphilitic taint, but 
the mercurial treatment to which the mother was subjected. This 
opinion, however, is erroneous. The careful administration of mer- 
cury to a pregnant woman affected with syphilis affords the surest 
protection to her child ; and it is very rare for this mineral to pro- 
duce abortion unless given injudiciously and in such a manner as 
to irritate the stomach or intestines. 

When both parents are affected with syphilis at the time of con- 
ception, and the mother does not receive appropriate treatment in 
the early months of pregnancy, the foetus will rarely be carried to 
the full term of gestation. When only one parent is affected, it is 



PERIOD OF DEVELOPMENT. 665 

reasonable to suppose, with Diday, that the influence of the mother, 
from whom the foetus derives its nutrition, will be greater than 
that of the father ; although the contrary is maintained by Prieur, 
Lloyd, Wade, and Maisonneuve and Montanier. 

In most cases of abortion from syphilis the general health of the 
mother is in a very fair condition, so that the death and expulsion of 
the foetus cannot be ascribed to a deficient supply of nourishment. 
In many cases it is sufficiently accounted for by the changes which 
are found upon post-mortem examination to have taken place in 
the thymus gland, lungs, and liver, and which will hereafter en- 
gage our attention. The researches of Dr. Eobert Barnes have 
led him to believe that in some instances the immediate cause 
of the abortion consists in fatty degeneration of the maternal and 
foetal structures of the placenta, the result of defective nutrition. 
"In a placenta affected with fatty degeneration, the lobes of the 
placenta are altered in appearance, some of them being of a yellow, 
fatty color, brittle, and exsanguine ; the rest presenting their ordinary 
characters. Examined more minutely, the tufts are found to be 
glistening, hard, and tallowy, and not expanding when placed under 
water, as is the case with the villi of healthy placentas. Under the 
microscope, the villi are found to be studded with spherules and 
droplets of fatty matter and oil. The fatty material is found prin- 
cipally in the cells of the villi, and in the coats of the bloodvessels 
of the villi. "When the fatty degeneration of the vessels exists to 
any extent, the vessels do not carry red globules. The villi and 
the vascular loops affected with degeneration are knobbed and mis- 
shapen in appearance." * Abortion from syphilis is most frequent 
about the sixth month of gestation, but is by no means confined to 
this period. Eicord states his impression that abortion takes place 
earlier when the germ of the disease has been derived from the 
father alone. 2 

Period of Development. — In most cases, an infant affected 
with congenital syphilis does not present at birth any of the ordi- 
nary manifestations of the disease as they are commonly met with 
in the subjects of acquired syphilis, but is in an apparently healthy 

1 Tyler Smith, London Lancet, Am. ed., July, 1856, p. 4. 

2 Discussion before the Soc. de Chirurgie, Session of May 31, 1854; Gaz. des 
Hop., 1854, p. 296. 



666 CONGENITAL SYPHILIS. 

or even robust condition ; and when any traces of the inherited 
taint are manifest at this time, they usually consist of an eruption 
of pemphigus, or of lesions of the internal organs, rarely met with 
in adults. But although this is the general, it is by no means 
an invariable rule. Sir Astley Cooper has observed several cases 
of a copper- colored eruption upon the palms of the hands, soles of 
the feet, and buttocks, at birth ; Gilbert one of flat brownish-red 
pustules (condylomata) scattered over the back, buttocks, and 
thighs, and another of a similar eruption around the nates, both 
infants living but a few days; Guerard one of "tawny-colored spots 
which every one would recognize as syphilitic ;" Landman one of 
copper-colored stains upon the body and condylomata upon the 
labia majora. Simon has reported the case of a woman affected 
with syphilis who repeatedly aborted about the seventh or eighth 
month, and in each instance the foetus, which was born dead, bore 
evident traces of syphilis; Deville one of numerous and well- 
marked mucous patches upon different parts of the body; and 
Bouchut one of an infant, born at seven and a half months, who 
presented mucous patches and pustules of a brownish-red or copper- 
color upon the legs and arms, together with ulceration of the labia 
minora and onyxis upon all the fingers and toes. Cullerier, in ten 
years' service at the Hopital de 1' Our cine, Paris, met with only two 
cases of syphilitic eruptions at birth, one of roseola and the other 
of mucous patches about the anus. 1 Yictor de Meric states that 
out of forty-six cases of hereditary syphilis which have been under 
his care, and in which the children were born alive, in only two 
did the infants present at birth distinct symptoms of syphilis. We 
conclude that, with the exception of an eruption of pemphigus and 
specific changes in the viscera, syphilitic lesions manifest at birth, 
although sometimes met with, are quite infrequent. 

In the very great majority of cases, the symptoms of congenital 
syphilis make their appearance within the first few months after 
birth ; and this fact is of great importance, since, when the parents 
are the subjects of syphilis, and manifest anxiety as to the future 
of their offspring, exemption during the period referred to renders 
it highly probable that the child has escaped contamination. Of 
158 cases collected by Diday from various sources, the disease 
showed itself — 

1 Emile Vidal, De la Syphilis Cougenitale, These, Paris, 1860, p. 8. 



LATE DEVELOPMENT. 



667 



Before the completion of one mouth after birth in 

Before the completion of two months in 

Before the completion of three months in 

At four months in 

At five months in 

At six months in 

At eight months in 

At one year in 

At two years in 



45 
15 
7 
1 
1 
1 
1 
1 



It appears from this table that the greater proportion of out- 
breaks of constitutional syphilis in tainted infants occur within the 
first three months after birth ; and that when this period is passed 
in safety, there is not much probability that any symptoms of the 
kind will manifest themselves. 1 

Other authors have arrived at similar conclusions. Trousseau 
states that, as a general rule, congenital syphilis appears within 
the first month; sometimes during the second, third, or fourth; 
rarely as late as the fifth; and that he has met with but one 
instance as late as the seventh month. 2 According to Cullerier, it 
is rare for infants affected with hereditary syphilis to pass six 
months without the disease appearing ; he has, however, witnessed 
its development in the eighth, ninth, and tenth month, but never 
after a year from birth. 

So far as known facts enable us to judge, Diday concludes that 
there is no relation between the period of development, the charac- 
ter and progress of congenital syphilis, and its particular mode of 
origin ; in other words, that the evolution and nature of the symp- 
toms will be essentially the same, whether the infant has derived 
the germ of the disease at the time of conception or during preg- 
nancy. 

Late Development of Congenital Syphilis. — We have seen that 
congenital syphilis almost invariably shows itself within a year, 
and, in the immense majority of cases, within three months after 
birth, and that the exceptional cases thus far mentioned do not 
greatly exceed the former limit. But an important question here 
arises, viz., whether the period of its latency may be indefinitely 
prolonged, and a child carry the germ of the disease undeveloped 
in its system until puberty or even adult life before it betrays itself 
by external manifestations? The solution of this question is sur- 
rounded by many difficulties, since it requires that the syphilitic 



Diday, op. cit. 



Union Medicale, 1857, p. 182. 



668 CONGENITAL SYPHILIS. 

nature of the symptoms, the absence of direct contagion, and the 
previous infection of the parents should be clearly established. 
Many of the facts reported fail to satisfy these conditions; yet 
others render an answer in the affirmative highly probable. Diday 
quotes the following cases: — 

A washerwoman of Orleans, of bad constitution, but tolerably healthy 
up to that period, married in 1824. She was delivered at the full time 
of a male child, which wasted rapidly, and sank on the seventeenth day, 
with small white pimples around the nails. At the end of a year she had 
a second child, now more than two years old, and healthy. 

A short time after having weaned it, she observed three swellings de- 
velope themselves upon her own body, one on the left clavicle, the second 
at the inner edge of the right sterno-cleido-mastoideus muscle, and the 
third near the elbow on the same side. The first soon suppurated, and 
the orifice was converted into a large ulceration. 

This woman, when the disease had existed five months, came into the 
hospital. At the spot indicated, an ulcer with red, abrupt edges, and a 
grayish base, was observed. She had, farther, a painful node on the left 
tibia. No trace of primary venereal affection could be discovered on the 
genital organs of this woman. She asserted that she had never had con- 
nection with any one but her husband, who, by his own account, had never 
had syphilis before marriage, and had always been healthy since. But she 
knew that her father had several times communicated the venereal disease 
to her mother, and that the latter had been suffering from it when she 
herself was born. Mercurial treatment rapidly effected the cure of the 
ulcer. 1 

We find also in Rosen the case of a young girl of eleven, fresh as a 
rose, in whom hereditary syphilis manifested itself in the form of swelling 
and suppuration of the glands of the neck and of the nose, of caries of 
the palate, and of corroding ulcers of the face. 3 

The work of Cazenave 3 on syphilitic affections contains two cases of 
disease called by him hereditary syphilis, occurring in two girls, one of 
nine years old, the other of eighteen, in the latter of whom the symptoms 
had first shown themselves at the age of ten. They had tubercular and 
serpiginous eruptions, which had produced serious effects. It was impos- 
sible to discover any trace of primary lesions, the existence of which was, 
moreover, rendered very improbable by the age at which the secondary 
phenomena had appeared. The first was cured by the administration of 
the protiodide of mercury. 

1 Gibert, Journ. Univ. des Sciences Med., t. Iv. p. 100. 

2 Maladies des Eufants, p. 843. 3 Traite des Syphilides, p. 542. 



LATE DEVELOPMENT. 669 

Trousseau has related the history of a young girl of nineteen, in whom he 
himself observed, in 1826, a chancre (?) in the posterior part of the throat. 
She had bad, at six years of age, exostoses on the legs, and during the 
six following years nocturnal pains, which did not cease until the appear- 
ance of the menses, and afterwards returned. There was probably, says 
Trousseau, hereditary or acquired syphilis at the moment of her birth. 
These symptoms were cured by anti-syphilitic treatment. 

Sperino 1 saw a child born of a mother who died of syphilis ; this 
child, previously healthy, though puny and scrofulous, was attacked by 
ulceration of the palate at the age of eleven years. Treated only with 
antiphlogistic and anti-scrofulous remedies, the ulcer continued to extend, 
and, after having destroyed the soft palate, it perforated the hard palate. 
These changes had required two years for their completion. When Spe- 
rino saw this child, at the age of thirteen, it was pale, emaciated, had 
purulent expectoration, almost incessant cough and fever, with evening 
exacerbations. He believed at first in the existence of pulmonary tuber- 
cles, but auscultation showed that none existed. The syphilitic character 
of the lesion having been diagnosed, syphilization was commenced. But 
in spite of the evident amelioration which ensued, fresh ulcers having ap- 
peared in the throat after four months of this treatment, recourse was 
had to iodide of potassium, which, given to the extent of 630 grains, 
completed the cure. 

Eicord does not hesitate to admit the late development of con- 
genital syphilis, which he would attribute to the effect of treatment 
administered to the mother during pregnancy; and he inquires, 
with much plausibility, why specific remedies, which are capable 
of retarding the evolution of general symptoms in the adult, may 
not similarly affect the foetus in utero. 2 Fournier 3 gives a brief 
summary of two cases, occurring in patients aged eighteen and twen- 
ty-five, who presented nearly the same symptoms, viz., a gummy 
tumor of the velum palati and an ulcerated tubercle on the poste- 
rior wall of the pharynx, which, in the absence of any evidence 
of direct contagion, were ascribed by Eicord to hereditary taint ; 
and the latter surgeon states that he has "seen subjects in whom 
hereditary syphilis did not manifest itself before the age of forty." 4 

In this connection I would refer the reader to Mr. Hutchinson's 

1 La Sifilizzazione Studiata qual Mezzo, etc., 1853, p. 454. 

3 Discussion on Hereditary Syphilis before the Soc. de Chirurg., Session of May 
31, 1854. 

3 De la Contagion Syphilitique, p. 11. 

4 Discussion before the Academie Imperiale de Medecine, Session of Oct. 8, 1853. 



670 CONGENITAL SYPHILIS. 

views of the syphilitic nature of "strumous keratitis," so-called, 
and notching of the permanent incisor teeth, already mentioned in 
the chapter upon syphilitic affections of the eyes. 1 

Symptoms. — Many of the symptoms of congenital are identical 
with those of acquired syphilis, and do not require special descrip- 
tion at this time ; I shall, therefore, dwell chiefly upon those which 
are peculiar to the subjects of an inherited taint. 

General Aspect of Syphilitic Infants. — Infants affected with con- 
genital syphilis do not, as a general rule, present any peculiarity 
of appearance at birth, but, soon after the evolution of general 
symptoms, they almost always waste away and assume a withered 
aspect similar to that observed in the aged, and which has been 
denominated " miniature decrepitude." The skin loses the smooth- 
ness and freshness of early life, and is wrinkled and sallow ; the 
cheeks and eyes are sunken ; the borders of the mouth are thrown 
into radiated folds, as if drawn together with a purse-string ; the 
palms of the hands and soles of the feet are dry, wrinkled, and 
often chapped ; and the general aspect of the child is one of pre- 
mature old age. In many cases, the skin assumes a peculiar bistre 
tint, which is regarded as quite characteristic of congenital syphilis 
by Trousseau, who describes it as follows : " The bistre tint is rarely 
absent, though it varies in extent, in intensity, and in the time of 
its appearance. Sometimes it occupies nearly the whole surface of 
the skin, but even then is most decided in its seat of election ; at 
other times it is confined to the face, certain, portions of which are 
most apt to be affected. As a general rule, it is less marked the 
more widely it is diffused. Its favorite seat is upon the lower 
portion of the forehead, the nose, the eyelids, and the most promi- 
nent portions of the cheeks. The deeper parts, as the internal 
angle of the orbit, the hollow of the cheeks, and the depression 
which separates the lower lip from the chin, are almost always 
exempt, but no invariable limits can be assigned to it." 2 

Coryza. — This is one of the earliest and most frequent manifesta- 
tions of congenital syphilis, and, in a few instances, is the only 
symptom present. It commences with a thin serous discharge from 
the nostrils, the margins of which are observed to be reddened, 

i See p. 616. 

8 Arch. Gen. de Med., 4e serie, t. xv. p. 159, 1847. 



SKIN AND MUCOUS MEMBRANES. 671 

and covered with small pustules, mucous patches, or fissures. As 
the disease progresses, the discharge becomes purulent and sanious ; 
the nasal passages are obstructed by the desiccation of matter and 
the formation of scabs; respiration is attended with a peculiar 
snuffling, which is very characteristic of this affection; and the 
impossibility of breathing freely through the nose seriously inter- 
feres with or altogether prevents suction at the breast ; thus the 
nutrition of the child is impaired, and death sometimes occurs 
from inanition. In severe cases, the osseous and cartilaginous 
tissues are attacked ; small fragments of necrosed bone come away 
with the discharge, and the septum nasi may be perforated, or the 
nose sunken. The disease sometimes involves the throat and 
larynx, and renders the voice hoarse or almost inaudible. Syphi- 
litic coryza commences in the mucous membrane, which, as shown 
by Diday, is the seat of mucous patches or pustules similar to those 
found upon other mucous surfaces. These are succeeded by ulcer- 
ations which involve the bones and cartilages secondarily. 

Affections of the Shin and Mucous Membranes. — A still more 
frequent and characteristic symptom of congenital syphilis, and 
one which is very rarely wanting, is an eruption of mucous patches. 
In infants, as well as in adults, the favorite seat of this eruption is 
in the neighborhood of the outlets of mucous canals, and especially 
in the vicinity of the anus ; but, owing to the general moisture of 
the integument at this early age, mucous patches are often much 
'more extended than in adults, and may occur upon any part of the 
surface. They are most frequent upon the nates, scrotum, vulva, 
thighs, around the umbilicus, in the axilla?, behind the ears, and 
upon the labial commissures ; they are also seen upon the hairy 
scalp, where they are never met with in adults. They are gener- 
ally distinct upon the thighs and trunk, but are often confluent in 
the genito-crural fold and around the margin of the anus, and in 
the latter situation frequently become ulcerated, and give rise to 
rhagades or fissures which radiate from the anal orifice. They 
exhale a very offensive and characteristic odor, especially if atten- 
tion to cleanliness be neglected. 

When seated upon a mucous surface, these patches present an 
opaline appearance, as if pencilled over with a crayon of nitrate of 
silver. They are rare upon the tongue, but frequent upon the in- 
ternal surface of the lips and cheeks, at the base of the gums, and 
upon the fauces, and in these situations are a common source of 



672 CONGENITAL SYPHILIS. 

contagion from the infant to the nurse. Whether seated upon the 
skin or mucous membranes, the appearance of this eruption does 
not materially differ from that already described in a previous 
chapter. 

Syphilitic erythema is rare in the subjects of congenital syphilis, 
although a number of cases have been reported. Bassereau men- 
tions an instance, in which red spots appeared upon the brow and 
cheeks the third day after birth, and presented the copper color 
and slight elevation peculiar to the papular form of syphilitic 
erythema. Syphilitic coryza appeared upon the fourth day, and 
the infant died at the end of a fortnight. 1 

Pemphigus, unlike other syphilitic eruptions, is frequently present 
at birth. It is characterized by large vesicles, filled with yellowish 
serum often mixed with blood, and resting upon violet-colored or 
bluish patches of integument. Its favorite seat is upon the palms 
of the hands and soles of the feet, although it sometimes occurs 
elsewhere. In most cases, some of the vesicles have been ruptured 
previous to the birth of the child, and the underlying skin is found 
to be reddened and superficially eroded, or, in some instances, more 
or less deeply ulcerated. The prognosis is exceedingly unfavora- 
ble, since death ensues in the great majority of cases. In other 
instances, syphilitic pemphigus does not make its appearance until 
a few hours or days after birth, and, if the child survives, the erup- 
tion usually disappears within three weeks. There has been no 
little discussion whether the pemphigoid eruption of infants is to 
be regarded as the immediate result of syphilis, or as the conse- 
quence of the general cachexia produced by the inherited taint ; 
this question, however, is of minor importance, since the eruption 
is rarely, if ever, met with in the offspring of other than syphilitic 
parents. 

Other syphilitic eruptions occurring in the subjects of congenital 
syphilis are pustules (syphilitic impetigo and ecthyma), and deep 
tubercles of the cellular tissue. Syphilitic papulae and squamas, 
and the non-ulcerated form of tubercles, are rare at this age. 

Onychia. — Syphilitic onychia is sometimes observed in infants, 
but is rarer than in adults. 

Suppuration of the Thymus Gland. — Paul Dubois, 2 in 1850, first 
called attention to certain pathological changes which are found 

1 Op. cit., p. 541. * Gaz. Med. de Paris, 1850, p. 392. 



CHANGES IN THE LUNGS. 673 

in the thymus glands of infants who are born dead, or who die 
a few days after birth from inherited syphilis. Externally, the 
gland appears to be normal in size, color, and consistency; but 
if an incision be made into its substance, pressure will cause to 
exude from the cut surface a few drops of yellowish fluid, which, 
under the microscope, is found to consist of pus. In the cases 
observed by Dubois, the purulent matter was uniformly diffused 
throughout the glandular tissue; but Depaul, 1 Weber, 2 and Hecker 3 
have met with abscesses of the thymus. The thymus gland natu- 
rally contains a whitish, viscid fluid, which may, with a little care, 
be distinguished from the suppuration dependent upon syphilis. 
Of five cases of this lesion observed by Dubois and Depaul, an 
eruption of pemphigus was present in four ; and in the same 
number the syphilitic antecedents of the parents were clearly estab- 
lished. Yirchow 4 mentions a case reported by Lehmann, in which 
tuberosities of the conjunctive tissue, which had undergone fatty 
degeneration, were found in the thymus gland, the dura mater, and 
the liver, but the history of the parents could not be ascertained 
with certainty. 

Changes in the Lungs. — In 1851, Depaul called the attention of 
the profession to peculiar masses of induration which he found in 
the lungs of infants affected with congenital syphilis. Specimens 
of this lesion furnished by Depaul were submitted by the Anatomi- 
cal Society of Paris to Lebert for examination, who reported upon 
them as follows : " There is no trace of pus in the masses of indu- 
ration. The tissue presents a peculiar yellow color, and is elastic 
and resistant. In the midst of a network of the normal pulmonary 
tissue we find, mingled with fibro-plastic elements, a soft, pulpy, 
diffused substance, containing small cells, which differ from those 
of cancer and of tubercle, and which resemble in every respect 
those seen in syphilitic gummata. These specimens may, therefore, 
be regarded as an early stage of pulmonary gummata, which first 
appear as indurated masses, and afterwards assume a yellowish 
and pulpy appearance, and finally soften so as to resemble puru- 
lent infiltration or abscesses." 5 In his Treatise upon Pathological 

1 Gaz. Med. de Paris, 1851. 

2 Beitrage zur Path. Anat. der Neugeboren. Kiel, 1852, vol. ii. p. 75. 

3 Verbandl. der Berliner Gesells. fur Geburtsliiilfe, vol. viii. p. 117. 

4 La Syphilis Constitutionnelle, p. 158. 

5 Bulletin de la Soc. Anatomique, 1852, p. 23. 

45 



674 CONGENITAL SYPHILIS. 

Anatomy, Lebert gives a plate of one of these masses of induration, 
which he compares to certain changes produced by pneumonia. 1 

Yirchow thus describes the results of his post-mortem investi- 
gations : " At Wlirzburg, where hereditary syphilis is very com- 
mon, I have found a large number of children die in consequence 
of a peculiar form of broncho-pneumonia. Microscopical examina- 
tion has shown the existence of a dry and resistant substance, very 
analogous to tubercular infiltration, which was inclosed in the pul- 
monary alveoli and consisted of cells pressed against each other, 
and for the most part puriform. The larger portion of this sub- 
stance, speedily underwent fatty metamorphosis, and remained in 
the pulmonary vesicles in the form of granular detritus. But I 
have also observed this lesion independent of any direct connection 
with syphilis. In children who were simply atrophied, I have 
found in many cases quite an abundant infiltration around the 
bronchi, where they penetrate into the pulmonary lobules, together 
with granular collections and abscesses, perfectly resembling what 
is called tubercle, and also distributed in the lungs. At present, 
it is difficult to determine how we are to recognize the syphilitic 
character of such pneumonias ; and I forbear from expressing an 
opinion upon certain cicatricial and caseous lesions, some of which 
are very probably due to syphilis." 2 

Changes in the Liver. — Of the various changes in the viscera 
which have been ascribed to syphilis, there is the least doubt re- 
specting those occurring in the liver, which were first noticed by 
Gubler in 1848. 3 Diday's description of this lesion is so clear and 
complete, that I shall avail myself of it. 

" When the lesion has reached its maximum, the liver is sensibly 
hypertrophied, globular, and hard. It is resistant to pressure, and 
even when torn by the fingers its surface receives no indentation 
from them. The elasticity of the organ is such, that if a wedge- 
shaped piece taken from its thin edge be pressed, it escapes like a 
cherry-stone, and rebounds from the ground. When cut into, it 
creaks slightly under the scalpel. The distinct nature of its two 
substances has completely vanished. On a uniform yellowish 
ground, a more or less close layer of small, white, opaque grains 
is seen, having the appearance of grains of semola, with delicate 
arborescences, formed of empty bloodvessels. On pressure no blood 

' Traite d'Anatomie Pathologique, PI. XIII., Figs. 3 and 4. 
2 Op. cit., p. 156. 3 Gaz. des Hop., 1848. 



CHANGES IN" THE LIVER. 675 

is forced out, but only a slightly yellow serum, which is derived 
from the albumen. Gubler has only three times seen the change 
carried to this extent. It is most frequently much less marked. 
Thus, the tissue of the organ is firm, without having that extreme 
hardness and yellow color which might admit of comparison to 
some kinds of flint. The interior of the organ presents rather an 
indefinite color, shaded with yellow or brownish-red, more or less 
diluted ; but in no part is the parenchyma quite healthy in appear- 
ance. 

" Again, the change may be found in circumscribed parts only. 
Gubler has seen it confined to the left lobe, to the thin edge of the 
right lobe, and to the lohulus Spigelii. He ascertained by injections 
that, in the indurated tissue, the vascular network is almost imper- 
meable ; that the capillary vessels are obliterated, and that even the 
calibre of the larger vessels is considerably diminished. Micro- 
scopical examination enabled him to discover the cause of this dis- 
position by revealing in the altered tissue of the organ, in every 
degree of change, the presence of fibro-plastic matter, sometimes 
in considerable, sometimes in enormous quantity. In the portions 
intervening between the diseased parts, the cells of the hepatic 
parenchyma maintain all the characteristics of their normal condi- 
tion. The physical consequences of the deposit of these elements 
are an increase in the volume of the liver, the compression of the 
cells of the acini, the obliteration of the vessels, and the consequent 
cessation of the secretion of bile. In all the subjects examined 
after death by Gubler, he always found the bile in the gall-bladder 
of a pale yellow color and very sticky; that is to say, very rich in 
mucus and very poor in coloring matter. 

"The blood had almost always undergone a marked change, its 
solid portion having the consistence of soft currant jelly and the 
fluid portion being unusually abundant. In one subject this change 
coincided with an extreme discoloration of all the tissues and with 
innumerable ecchymoses. In one case the lungs presented the 
characters of acute pneumonia, and in two that of chronic or pan- 
creatiform pneumonia. Lastly, the concomitant syphilitic lesions 
consisted in patches of psoriasis, pustules of lenticular ecthyma, 
mucous patches, fissures at the circumference of the natural outlets, 
and in the folds about the joints, and inflammation of the nasal 
fossae, with purulent and sanguineous secretion." 1 

1 Syphilis in New-born Children ; Sydenham Society's translation, p. 92. 



676 CONGENITAL SYPHILIS. 

Gubler regards this lesion as of the same nature as gummy 
tumors, and consequently classifies it among tertiary symptoms. 
Diday, on the other hand, looks upon induration of the liver as 
identical with that of the base of the chancre and neighboring gan- 
glia, and therefore assigns its place among secondary lesions. The 
fact that it yields most readily to mercurials appears to favor the 
latter classification. 

The symptoms of this affection, so far as they have been deter- 
mined, are excessive restlessness of the infant, who is apparently 
in great pain, vomiting and diarrhoea, or constipation, swelling and 
tenderness of the abdomen, and a small and quick pulse. By pal- 
pation and percussion, an increase in the volume and density of the 
liver may, perhaps, be ascertained. Jaundice has never been noted 
in any of the reported cases ; although, according to Emile Tidal, 1 
Ghibler has met with one instance not yet published. The prog- 
nosis in this affection is very unfavorable, and death generally 
ensues in a very few days. 

Peritonitis. — Prof. Simpson, 2 of Edinburgh, in a large proportion 
of the cases in which the children of syphilitic parents die during 
the latter months of pregnancy, ascribes the mortality to peritoni- 
tis ; farther observation, however, is requisite to determine whether 
congenital syphilis is capable, of producing simple peritonitis inde- 
pendently of induration of the liver, with which it was associated 
in some of Gubler's cases. 

Affections of the Periosteum and Bones. — These affections, although 
occasionally met with as an effect of congenital syphilis, are con- 
fessedly rare. In addition to the cases referred to upon page 465 
of the present work, the following have been reported. 

Underwood 3 saw an exostosis upon the cranium of a child, born 
of a syphilitic mother who had been infected by her husband. 

Bertin 4 met with a periostosis upon the superior and posterior 
surface of the cubitus, in an infant thirty-five days old, whose body 
was covered with pustules. 

Laborie 5 mentions a case of caries of the tibia in a subject of 
congenital pemphigus. 

1 De la Syphilis Congenitale, Paris, 1860, p. 32. 

2 Obstetric Memoirs, Edinb., 1856, vol. ii. p. 172. 

3 Traite des Mai. des Enfants, Paris, 1786, p. 361. 

4 Traite de la Mai. Verier, chez les Enfants Noiweau-nes, p. 69. 

5 Session of the Acad, de Med., July 1, 1857. 



PROGNOSIS. 677 

Cruveilhier 1 speaks of a child born at full term, poorly devel- 
oped, with pustules on different parts of the body, in whom the 
dura mater, corresponding to the angle of union of the frontal 
bones with the superior walls of the orbits, was infiltrated with pus, 
and the bones themselves denuded and eroded in a part of their 
thickness. 

Bouchut 2 has described an affection of the long bones, differing 
from caries and degeneration of the periosteum, which he states he 
has often observed in the subjects of inherited syphilis. Instead 
of the soft, spongy, vascular, imperfectly formed and easily cut 
structure of the bones at this age, he has found the middle portions 
of the tibiae and femora, solid, compact, eburnated, and not to be 
broken or divided by a cutting instrument. Bouchut supposes 
that these changes indicate an abnormal activity in the development 
of bony tissue, similar to the plastic exudation which takes place 
in other organs. 

Hydrocephalus. — Hydrocephalus has been attributed to an in- 
herited syphilitic taint by Gros and Lancereaux, 3 Eayer, Haase, 4 
and De Meric; 5 and several cases have been reported in which 
the connection as cause and effect between these two diseases has 
appeared to be highly probable. 

Affections of the Supra-renal Capsules and Pancreas. — Yirchow 6 
states that he has met with an increase of volume and complete 
fatty degeneration of the supra-renal capsules, and also fatty degen- 
eration of the pancreas, in infants affected with congenital syphilis. 

Prognosis. — The mortality from congenital is undoubtedly much 
greater than from acquired syphilis, although statistics to determine 
the exact proportion of deaths are wanting. Bassereau 7 says that 
an examination of his notes and of cases reported by others leads 
him to believe that in at least one -third, death ensues within a few 
months after birth. Trousseau 8 has never seen an infant recover 
when the disease appeared within a few days after delivery. 

1 Anatomie Patliologique, 10th obs. 

2 Traite Pratique des Mai. des Nouveaux-nes, 1852, p. 863. 

3 Memoire crowned by the Academy, 1859 (as quoted by Emile Vidal, op. cit., 
p. 33). 

4 Allgemein. Medic. Annal., Feb. 1829, p. 194. 

5 Lettsomian Lectures, 1858, p. 65. 

6 La Syphilis Constitutionnelle, p. 161. 7 Op. cit., p. 544. 
8 Lemons sur la Syphilis CongSnitale, Union Medicale, 1857. 



678 CONGENITAL SYPHILIS. 

Treatment. — The propriety of treating a pregnant woman for 
syphilis has been the subject of much discnssion ; and has, at times, 
been denied on the ground that mercury was a powerful cause of 
abortion, and that the death and expulsion of the foetus was more 
frequently due to the administration of this mineral than to syphilis 
itself. It would serve no useful purpose to enter into the arguments 
which have been advanced for and against this supposition; suffice 
it to say that modern surgeons, with but few exceptions, regard the 
fear referred to as chimerical, and believe that specific treatment of 
the mother is the surest means of prolonging gestation to its full 
term and of affording security to the infant after birth. Eicord's 
views upon this subject are very explicit and decided. He says: 
" The period of gestation in women, far from contraindicating ener- 
getic treatment, demands increased attention and promptitude within 
the bounds of prudence. I have seen very many more abortions 
among syphilitic women who had not been treated, than among those 
who, taken in time, had been subjected to methodical medication." 

There is strong ground for believing that in those cases in which 
mercurials have appeared to favor abortion, they have done so only 
in consequence of their irritant effect upon the intestinal canal, and 
not from any abortive power inherent in the remedy itself. Thus, 
six cases reported by Colson 1 of abortion in pregnant women who 
were subjected to mercurial treatment, were analyzed by Bertin, 2 
who showed that in four there was violent vomiting, and in a fifth 
convulsions at the sixth month of pregnancy ; while in the remain- 
ing case treatment had been commenced only a fortnight before, 
and sufficient time had not elapsed to obtain its full effect ; hence, 
that in none was there reason to ascribe the death of the foetus to 
the judicious employment of mercury. 

The sympathy existing between the intestinal canal and the 
uterus is well known, and in the treatment of pregnant women 
affected with syphilis, we should carefully guard against any irri- 
tant action upon the stomach or bowels. Fortunately, this end 
may be accomplished, and at the same time the full action of the 
remedy be obtained by mercurial inunction, which is by far the 
best method of treatment in such cases. The same opinion was 
expressed a long time ago by Bell, who said : " During pregnancy, 

1 Arch. Gen. de Med., 4tli series, t. xviii. p. 24. 

2 Compte Rendu des Travaux de la Soc. de Med. de Bruxelles, 1S58, p. 82 (as 
quoted by Eniile Vidal, op. cit., p. 84). 



TREATMENT. 679 

mercury ought in every instance to be used in the form of unction, 
as we thereby with most certainty prevent it from acting upon the 
stomach and bowels, and thus avoid the hazard of abortion taking- 
place as the effect of irritation upon these parts. Nothing, indeed, 
more readily excites abortion than purgatives when severe in their 
operation upon the bowels, or when they even only produce any 
considerable degree of tenesmus ; and as the internal exhibition of 
mercury is frequently the cause of this, it cannot but with much 
hazard be given in any considerable quantity during pregnancy." 

When the father is known to have been the subject of syphilitic 
manifestations at the time of impregnation, or when previous abor- 
tions afford reason for supposing that the disease, although appa- 
rently latent in him, has still been active enough to infect the 
ovum, it is the part of prudence to subject the mother to treatment 
during pregnancy, in the same manner as if she herself had pre- 
sented syphilitic symptoms. 

The same method of treatment above recommended for the 
mother, viz., mercurial inunction, is no less appropriate for an 
infant affected with congenital syphilis. The internal administra- 
tion of mercury, as in one of the accompanying formulas, will some- 
times succeed, but too frequently irritates the bowels, and, in my 
own experience, affords far less satisfactory results than the method 
by inunction. 

R. Hydrargyri cum creta gr. ij-vj. fy. Hydrarg. chloridi corrosivi gr. ss-j. 

Sacchari albi gr. xij. Ammonia? muriatis gr. iij. 

M. et div. in ch. No. xii. Syrupi papaveris :§ij. 

One three times a day. Aquse ^fiv. 

M. A teaspoonfnl three times a day. 

Yan Swieten's solution and Plenck's gummy mercury 2 are often 
used by the French, who also employ baths containing from half a 
drachm to a drachm of the bichloride of mercury. My own prefer- 
ences are in favor of the gray powder for internal administration. 

The advantages of mercurial inunction and the method of em- 
ploying it are thus set forth by Sir Benjamin Brodie: 3 " The mode 

! A Treatise on Gonorrhoea Virulenta, &c.,JEdinb., 1793, vol. ii. p. 435. 

2 " Plenck's gummy mercury" contains mercury gr. xv, powdered gum Arabic 
gr. xlv, and syrup of diacode (an electuary containing a small quantity of extract 
of poppies) 3j. Triturate in a porcelain mortar until the mercury disappears. 
Dose. — £ss in an appropriate vehicle. (Diday.) 

8 Clinical Lectures on Surgery, Phil, ed., 1846, p. 230. 



680 CONGENITAL SYPHILIS. 

in which I have treated these cases for some years past has been 
this : I have spread mercurial ointment, made in the proportion of 
a drachm to an ounce ; over a flannel roller, and bound it round 
the child once a day. The child kicks about, and, the cuticle being 
thin, the mercury is absorbed. It does not either gripe or purge, 
nor does it make the gums sore, but it cures the disease. I have 
adopted this practice in a great many cases with the most signal 
success. Very few children recover in whom mercury is given in- 
ternally, but I have not seen a case where this method has failed." 

Treatment should by no means be laid aside as soon as all syphi- 
litic manifestations have disappeared, but should be continued as a 
prophylactic for several months afterwards. 

Indirect treatment by means of remedies administered to the 
child's nurse is not to be depended upon in a disease which makes 
such rapid progress and is so destructive in its tendency as con- 
genital syphilis. MM. Lutz and Personne have carefully analyzed 
the milk of nurses who were subjected to mercurial treatment, 
pushed in some instances to salivation, without being able to dis- 
cover the slightest trace of this mineral. Experiments upon animals, 
however, have shown that a very minute quantity of mercury may 
be detected in the milk of a goat that has been salivated by mer- 
curial inunction, and cases have been reported in which infants 
have been cured of syphilis by being fed upon milk derived from 
such a source ; but this method, for obvious reasons, could not be 
generally adopted, even if its efficacy were fully established. 

The administration of iodide of potassium to the infant's nurse 
may be resorted to with much greater probability of the remedy 
finding its way into the mammary secretion, and may often be em- 
ployed with advantage as an adjuvant to the direct treatment of 
the child. 

The local treatment of syphilitic symptoms is the same in the 
child as in the adult ; but the utmost cleanliness should be main- 
tained and the affected parts be carefully preserved from contact 
with the urine and feces. 



INDEX. 



Abortion, 664 

Abortive treatment of chancres, 404 

of gonorrhoea, 56 
Acetate of zinc injections, 69 
Acne, 564 

Adams, prostatitis, 139 
Alopecia, 575 
Alum injections, 70 
Amaurosis, 631 

American origin of syphilis, 24 
Anti-blennorrhagics, 72 
Aphonia, 605 
Aphthae, 591 

Arabian treatment of syphilis, 499 
Aromatic wine, 167 

Astruc, diminished intensity of syphilis, 
348 

epochs of syphilis, 31 
Auzias-Turenne, syphilization, 533 



B 



Babixgton, induration, 378 
Balanitis, 99 

causes, 99 

symptoms, 100 

treatment, 100 
Bassereau, engorgement of cervical gan- 
glia, 548 

syphilitic virus, 332 

incubation of general symptoms, 
455 

history of venereal diseases, 17, 25 

prognostic value of suppuration in 
buboes, 435 
Beadle, dry gonorrhoea, 46 
Benzoic acid, 281 
Bichloride of mercury, 518 
Bigelow (Dr. H. J.), model bougies, 278 
Bismuth injections, 71 
Black wash, 418 
Bladder, inflammation of, 146 

puncture of, 318 

in stricture, 258 



Blancard's pills, 528 
Blennorrhagia, 39 
Blisters in gleet, 96 

treatment of syphilis, 543 
Blood, contagion of, 482 

state of, 547 
Boeck, syphilization, 535 
Bones, affections of, 652 
in infants, 676 

effects of mercury, 515 
Bonnet, extirpation of eye, 191 
Bougies, 274 

twisted, 274 

bulbous and knotted, 276 

model, 278 

in gleet, 90 
Bouisson, muscular tumors, 644 
Boutonniere operation, 299 
Brassavolus, history of syphilis, 28 
Bridle stricture, 250 
Brockedon's wafers, 63 
Buboes, 426 

gonorrhoeal, 44 
in women, 161 

simple, 427 

virulent, 427 

indurated, 430 

prognostic value of suppuration, 433 

d'emblee, 437 

treatment, 440 

constitutional, 447 
method of opening, 443 
Buchanan's instrument, 289 
Buck (Dr. Grurdon), perineal fascia, 232 
Bullae, 561 



Camphor, in chordee, 81 
Canada turpentine, 80 
Canquoin's paste, 414 
Cantharides in gleet, 90 
Capsules of copaiba, 76 
Carbo-sulphuric paste, 414 
Caries, 657 
Carmichael, plurality of poisons, 330 



682 



INDEX. 



Castelnau, epididymitis, 115 
Catheters, 272 

curvature, 273 

introduction, 276 
Caustics in stricture, 291 
Cazenave, incubation, 457 
Cephalic chancre, 358 
Chabalier, history of venereal, 17 
Chancres, definition, 355 

seat, 355 

contagion, 358 

form, 361 

classification, 366 

simple, 367 

infecting, 369 

Hunterian, 369 

" parchemines," 376 

complications, 386 

inflammatory, 386 

phagedenic, 387 

diagnosis, 390 

capable of spontaneous cicatrization, 
395 

" larves," 422 

of urethra, 54, 422 

of the fraenum, 42.1 

of vagina, 424 

of anus and re 

of mouth, 425 

treatment, 394 
general, 395 
abortive, 404 
topical applications, 417 
Chancroid, 367 

definition of, 355 

distinct from syphilis, 332 

history of, 19 
Chlorate of potash, 513 
Chloride of zinc injections, 69 
Chordee, 43 

treatment, 80 
Choroiditis, 629 
Circumcision, 107 
Civiale's urethrotome, 297 
Clerc, syphilitic virus, 338 
Colly ria, gonorrhoeal ophthalmia, 188 
Columbus, origin of syphilis, 24 
Compressor urethrae muscle, 236 
Condylomata, 581 
Congenital syphilis, 660 

etiology, 660 

transmissibility, 663 

period of development, 665 

symptoms, 670 

prognosis, 677 

treatment, 678 
Conjunctiva, syphilitic affections, 615 
Consecutive symptoms defined, 354 
Constitutional syphilis defined, 353 
Contagion, mediate, 360 
Copaiba, 72 

formulae containing, 74 



Copaiba, solidified, 75 

capsules of, 76 

dragees of, 76 

by the rectum, 77 

cutaneous eruptions, 77 

action on kidneys, 77 
Copper color, 551 
Cornea, affections of, 615 
Corpora cavernosa, 228 
Corpus spongiosum, 227 
Coryza, in infants, 670 
Cubebs, 75 

formulae containing, 76 
Cullerier, mediate contagion, 360 

tertiary enteritis, 600 
Cystitis, 146 



Danielssen, syphilization, 541 

De Baerensprung, classification of general 

symptoms, 466 
Demarquay, vaginitis, 169 
De Meric (Victor), incubation of general 

symptoms, 455 
Depaul, changes in the lungs, 673 
Destructive treatment of chancres, 410 
Diday, abortive treatment, 408 

bubo d'emblee, 438 

incubation of general symptoms, 
454 

inoculation of blood, 483 

self-limitation of syphilis, 495 

deep urethral injections, 96 

syphilization, 533, 540 

unicity of syphilis, 350 

syphilitic aphonia, 605 

syphilitic orchitis, 640 

gonorrhoea of the nose, 40 

leucorrhceal origin of gonorrhoea, 50 
Dilatation of strictures, 282 

continuous, 287 

rapid, 288 
Donne, trichomonas, 152 
Dry gonorrhoea, 46 
Dubois, thymus gland, 672 
Dupuytren's pomade, 577 
Duverney's glands, 155 



E 



Eak, affections of, 633 

Ecthyma, 566 

Elliot (Dr. Geo. T.), pelvic cellulitis, 163 

Epididymitis, 114 

causes, 115 

seat, 117 

symptoms, 120 

pathological anatomy, 128 

terminations, 121 



INDEX. 



683 



Epididymitis, duration, 121 

treatment, 130 
Epilepsy, 648 
Eruptions, syphilitic, 551 
Erythema, 555 

of mucous surfaces, 591 
Exostosis, 655 
Expansion of stricture, 290 
Extravasation of urine, 323 
Eyeball, protrusion of, 611 
Eyelids, affections of, 614 
Eyes, affections of, 611 



Fascije, perineal, 228 

Faye, syphilization, 538 

Fever, syphilitic, 546 

Fischer (Dr. H. E.), eruptions from 

iodine, 530 
Fournier, etiology of gonorrhoea, 50 

syphilitic virus, 341 
Fraenum, chancres of, 421 
French disease, 20 
Fricke, strapping testicle, 132 
Fumigations, mercurial, 505 



Gt 



Ganglia, engorgement of, 548 
Gangrenous chancre, 386 
Gargles, 597 

Gaussail, epididymitis, 123, 128 
General syphilis, 450 

always follows a chancre, 450 

period of incubation, 452 

classification, 460 

contagiousness, 467 

treatment, 494 
Gibert, inoculation of secondary symp- 
toms, 468 
Gleet, 83 

symptoms, 84 

pathology, 85 

contagion, 85 

treatment, 87 

injections, 92, 95 
blisters, 96 
Godard, epididymitis, 126 
Gonorrhoea, distinct from syphilis, 34 

history of, 18 

causes of, 46 

nature of, 46 

leucorrhoeal origin of, 46 

poison of, 55 

in the male, 39 
symptoms, 41 
duration, 82 
treatment, 55 

in the female, 149 



Gonorrhoea in the female, causes, 149 
symptoms, 152 
complications, 161 
diagnosis, 163 
treatment, 164 
of the rectum, 39 
of the anus, 39 
of the nose, 39 
from asparagus, 53 
" virulenta," 422 
Gonorrhoeal ophthalmia, 175 
causes, 177 
symptoms, ISO 
diagnosis, 183 
treatment, 183 
rheumatic, 202 
Gosselin, epididymitis, 124 
hypertrophy of labia, 424 
stricture of rectum, 601 
Grassi, analysis of blood, 548 
Graves, injection for gonorrhoea, 69 
Gross, prostatitis, 140 
Grunbeck, origin of syphilis, 21 
Gubler, affection of liver, 674 
Gummata, 586 



H 



Haieion, gonorrhoeal ophthalmia, 183 
Halsted (Dr. T. M.), treatment of chan- 
cres, 401 
Hancock, muscles of urethra, 226 

stricture of urethra, 244 
Hematuria, 263 

Hemorrhage from urethra, 43, 81 
Hereditary syphilis, 660 
Hermann, effect of mercury upon the 

bones, 515 
Huguier, glands of vulva, 154 
Hunt, treatment of syphilis, 521 
Hutchinson, infantile iritis, 625 

circumcision, 103 

notching of teeth, 616 
Hydrocephalus, 677 
Hygiene in syphilis, 497 



I 



Impermeable stricture, 252 
Impetigo, 565 

Impotence from epididymitis, 124 
Incision of stricture, 295 
_ internal, 296 

external, 299 
Incubation of chancres, 370 

of general syphilis, 452 
Induration, 374 

time of development, 377 

duration of, 378 

parchment, 376 



684 



INDEX. 



Infecting chancre, 369 

incubation of, 370 

forms of, 372 

induration of, 374 

usually single, 379 

not auto-inoculable, 380 

treatment, 395 
Inflammatory chancre, 386 
Injections, mode of using, 57, 67 

objections to answered, 66 

composition of, 68 

in gleet, 92 

for women, 165 

intra-uterine, 173 
Inoculation, artificial, 363 
Intestines, affections of, 599 
Inunction, mercurial, 508 
" Inversions du testicule," 118 
Iodide of iron, 528 
Iodide of potassium, stricture, 281 
Iodine, 524 

unpleasant effects of, 529 

eruptions from, 530 
Iodism, 531 
Iritis, 617 

infantile, 625 



Jameson, perineal section, 301 
John de Vigo, induration, 23, 374 



K 



Keeatitis, 615 



Malapert and Reynaud, buboes, 442, 446 
Maximilian I, decree " contra blasphe- 

mos," 21 
Meot's pills, 76 
Mercury, 500 

in primary sores, 395 

by fumigation, 505 

by inunction, 508 

salivation from, 510 

effect upon the bones, 515 

duration of treatment, 517 
Milk, contagiousness of, 663 
Milton, treatment of chordee, 81 

treatment of gonorrhoea, 62, 70 
Mixed chancre, 382 
Mucous membranes, affections of, 590 
Mucous patches, 579 

developed from a chancre, 381 

contagious, 482 

treatment of, 585 

in infants, 671 



N 



Naples, origin of syphilis, 20 

Necrosis, 657 

Nerves, affections of, 647 

Nitrate of silver injections, 57 

Nitric acid, 413, 533 

Nodes, 654 

Nose, affections of, 603 

Notta, muscular contraction, 642 



Lachrymal passages, affections of, 612 
Lacuna magna, 224 
Lafayette mixture, 74 
Laryngitis, 606 
Larynx, affections of, 605 
Ledwich, chronic prostatitis, 141 
Lee (Mr. Henry), infecting chancre, 347 
Lente, perineal section, 302 
Leroy d'Etiolles, twisted bougies, 275 
Lichen, 557 
Liver, affection of, 674 
Lungs, affections of, 673 
Lymphangitis, virulent, 429 
Lymphatics, induration of, 436 
inflamed in gonorrhoea, 44 



M 



Maisonneuve, " catheterisme a la suite," 
290 



(Esophagus, stricture of, 598 
Onychia, 577 
Opaline patches, 583 
Orchitis, 635 
Osteocopic pains, 653 
Ovaritis, gonorrhoeal, 162 



Panaris, 578 

Pancreas, affection of, 677 
Papules, 557 

Paralysis of nerves of the eye, 631 
Paraphymosis, 111 

Parker (Mr. Langston), effect of iodine 
upon the tongue, 531 

mercurial fumigation, 506 

treatment of buboes, 445 
Pelvic cellulitis, from gonorrhoea, 163 
Pemphigus, 561, 672 
Perineal section, 299 
Perineal testicle, 126 
Periosteum, affections of, 652 

in infants, 676 



INDEX. 



685 



Periostitis, 654 
Peritonitis, 676 
Peters (Dr. Geo. A.), bulbous souuds, 

275 
Phagedena, not due to a distinct virus, 

343 
Phagedenic chancre, 387 
prognostic value of, 389 
treatment of, 396, 403, 415 
Phillips, catheterism, 286 

impermeable stricture, 253 
gleet, 87, 90 
Phymosis, 103 

Piringer, gonorrhceal ophthalmia, 179 
Pityriasis, 559 
Plaques muqueuses, 579 
Plenck's gummy mercury, 679 
Poisons of gonorrhoea, the chancroid and 

syphilis, compared, 346 
Pomades for the hair, 576 
Porter (Dr. "SV. H.), contagiousness of 

the sperm, 487 
Potassio-tartrate of iron, 418, 404 
Pregnancy, vegetations, 221 
Primary symptoms defined, 353 
Probe-pointed catheter, 315 
Prostatitis, acute, 137 

chronic, 140 
Prostatorrhoea, 140 
Psoriasis, 559 
Puche, induration, 378 

auto-inoculation of chancre, 380 
Pustules, 564 
Pustulo-crustaceous eruption, 565 



R 



Rectum, stricture of, 601 
Resolvent ointment, 441 
Retention of urine, 264 

treatment, 312 
Retinitis, 629 

Rheumatoid neuralgia, 547 
Ricord, abortive treatment of chancres, 
405 

artificial inoculation, 363 

chlorate of potash, 513 

classification of general symptoms, 
460 

duration of mercurial treatment, 520 

engorgement of cervical ganglia, 
548 

incubation of general symptoms, 457 

injections in gonorrhoea, 71 

pad for buboes, 442 
Rilliet, iodism, 531 

Rinecker, inoculation of secondary symp- 
toms, 473 
Rochoux, epididymitis, 119 
Rollet, treatment of phagedena, 415 

contagiousness of secondary symp- 
toms, 476 



Rollet, distinction between gonorrhoea 
and syphilis, 33 

gonorrhceal rheumatism, 195 

mixed chancre, 384 
Roseola, 556 

Royet, " inversion du testicule," 118 
Rupia, 562 
Rupture of stricture, 291 



S 



Saint Yves, gonorrhceal ophthalmia, 175 

Salivation, mercurial, 510 

Salmon, gonorrhoea of the vulvo-vaginal 

gland, 156 
Sarsaparilla, 533 
Scanzoni, vaginitis, 169 
Scarlet fever, vaginitis, 151 
Secondary syphilis, 460 
Semen, contagiousness of, 486 
Sigmund, abortive treatment of chancres, 
405 

epididymitis, 117, 119 

incubation of general symptoms, 457 

protiodide of mercury, 503 

induration, 378 
Simple chancre, 367. See Chancroid. 
Simpson, medicated pessaries, 170 
Skey, origin of gonorrhoea, 51 
Skin, affections of, 551 
Smoking, in gonorrhoea, 65 
Sounds, 274 

bulbous, 275 
Speculum vaginae, 157 
Sperino, syphilization, 535 
Spermatorrhoea, 143 
Squamse, 559 

Stearate of iron pomade, 418 
Stewart's (Dr. F. C.) instrument, 60 
Stricture of oesophagus, 598 
Stricture of rectum, 601 
Stricture of urethra, 222 

transitory, 240 

organic, 243 

seat of, 246 

number, 250 

form, 250 

pathology, 254 

symptoms, 261 

constitutional effects, 260 

causes, 266 

diagnosis, 271 

treatment, 280 
Sub-pubic curve, 239 
Sulphate of zinc injections, 68 
Suppuration of buboes, prognostic value, 

433 
Suspensory bandage, 61 
Swelled testicle, 114 
Syme, impermeable stricture, 252 

perineal section, 299, 307 



686 



INDEX. 



Syphilis, history of, 20 

Italian epidemic, 20 

unicity of, 348 

nomenclature of, 353 
Syphilitic fever, 546 
Syphilization, 533 
Syphilodermata, 551 

characteristics of, 551 

classification of, 554 

treatment of, 572 
Syringes for urethral injections, 57 



T 



Tendons, affections of, 642 
Tertiary syphilis, 460 
Testicle, syphilitic, 635 
Thayer's fluid extracts, 533 
Thiry, " granular virus," 55 
Thompson, etiology of gonorrhoea, 51 

length of urethra, 237 

seat of stricture, 247 

causes of stricture, 266 

probe-pointed catheter, 315 

urethrotome, 298 
Thymus, affection of, 672 
Tobacco in gonorrhoea, 65 
Tongue, tubercles of, 594 
Trachea, affection of, 608 
Trichomonas, 153 
Tubercles, 568 

of the tongue, 594 

of the lips, 595 
Tyrrell, gonorrhoeal ophthalmia, 185 



U 

Ulcers, 572, 591 
Ulcus elevatum, 386 
Urethra, anatomy of, 222 

dimensions of, 236 

curves of, 239 

glands of, 224 
Urethral fever, 310 
Urinary abscess, 256 

treatment of, 324 
Urinary fistula, 256 
Urine, retention of, 264 

treatment, 312 



Vaccination, communication of syphilis, 

483 
Vaginitis, 157 

Van Buren (Dr. W. H.), tertiary symp- 
toms in congenital syphilis, 465 
Van Roosbroeck, gonorrhoeal ophthalmia, 
179 

poison of gonorrhoea, 346 
Van Swieten's liquid, 504 
Vegetable decoctions and infusions, 532 
Vegetations, 218 
Vella, history of venereal, 26 
Velpeau, epididymitis, 134 
Venereal diseases, history of, 17 
Vesicles, 560 

Vetch, gonorrhoeal ophthalmia, 177 
Vidal, epididymitis, 135 

incubation of general symptoms, 458 
Viennois, vaccination and syphilis, 483 
Virchow, absorption, 347, 429 

classification of general symptoms, 
466 

effect of mercury upon bones, 515 
Virus, syphilitic, 327 

duality of, 328 

compared with other poisons, 346 
Vulva, gonorrhoea of, 153 
Vulvo-vaginal glands, 155 



W 



Wade, caustics in stricture, 293 

Wakley's instrument, 289 

Waller, inoculation of secondary symp- 
toms, 483 

West, stricture of oesophagus, 598 

Whitlow, 578 

Wilde, diseases of ear, 633 

Wilks, pathology of affections of air-pas- 
sages, 593, 607 

Williams (Dr. H. W.), treatment of iri- 
tis without mercury, 623 



Zittman's decoction, 533 



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ROOM. With 266 illustrations. In one handsome royal 12mo. volume, of over 600 pages, extra 
cloth. $2 25. 



We believe it to be one of the most useful works 
upon the subject ever written. It is handsomely 
illustrated, well printed, and will be found of con- 
venient size for use in the dissecting-room. — Med. 
Examiner. 

However valuable may be the "Dissector's 
Guides" which we, of late, have had occasion to 



notice, we feel confident that the work of Dr. Allen 
is superior to any of them. We believe with the 
author, that none is so fully illustrated as this, and 
the arrangement of the work is such as to facilitate 
the labors of the student. We most cordially re- 
commend it to their attention. — Western Lancet. 



ANATOMICAL ATLAS. 
By Professors H. H. Smith aud W. E. Horner, of the University of Pennsyl- 
vania. 1 vol. 8vo., extra cloth, with nearly 650 illustrations. SSir See Smith, p. 26. 



ABEL (F. A.), F.C.S. AND C. L. BLOXAM. 
HANDBOOK OF CHEMISTRY, Theoretical, Practical, and Technical; with a 
Recommendatory Preface by Dr. Hofmann. In one large octavo volume, extra cloth, of 662 
pages, with illustrations. $3 25. 

ASHWELL (SAMUEL), M. D., 

Obstetric Physician and Lecturer to Guy's Hospital, London. 

A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. 

Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third 
and revised London edition. In one octavo volume, extra cloth, of 528 pages. $3 00. 



The most useful practical work on the subject in 
the English language. — Boston Med. and Surg. 
Journal. 



The most able, and certainly the most standard 
and practical, work on female diseases that we have 
yet seen. — Medico- C kirurgical Review. 



ARNOTT (WEILL), M. D. 
ELEMENTS OF PHYSICS; or Natural Philosophy, General and Medical. 

Written for universal use, in plain or non-technical language. A new edition, by Isaac Hays, 
M. D. Complete in one octavo volume, leather, of 484 pages, with about two hundred illustra- 
tions. $2 50. 

BIRD (GOLDING), A. M., M. D., &c. 
URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY, AND 

THERAPEUTICAL INDICATIONS. Edited by Edmund Lloyd Birkett, M. D. A new 
American, from the last and enlarged London edition. With eighty illustrations on wood. In one 
handsome octavo volume, of about 400 pages, extra cloth. $2 75. (Just Ready.) 

It can scarcely be necessary for us to say anything ■ to the extension and satisfactory employment of our 
of the merits of this well-known Treatise, which so i therapeutic resources. In the preparation of this 
admirably brings into practical application there- I new edition of his work, it isobvious that Dr. Gold- 
suits of those microscopical and chemical re- ing Bird has spared no pains to render it a faitnfu I 
searches regarding the physiology and pathology \ representation of the present state of scientific 
«.f the urinary secretion, which have contributed so i knowledge on the subject it embraces. — British and 
much to the increase of our diagnostic powers, and [ Foreign Med.-Chir. Review. 



BENNETT (J. HUGHES), M. D., F. R. S. E., 

Professor of Clinical Medicine in the University of Edinburgh, &c. 

THE PATHOLOGY AND TREATMENT -OF PULMONARY TUBERCU- 
LOSIS, and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistakes 
for or associated with, Phthisis. One vol. 8 vo., extra cloth, with wood-cuts. pp. 130. $1 25.. 

BARLOW (GEORGE H.), M. D. 

Physician to Guy's Hospital, London, <fcc. 

A MANUAL OF THE PRACTICE OF MEDICINE. With Additions- % D, 

F. Condie, M. D., author of " A Practical Treatise on Diseases of Children," &c. In one hand- 
some octavo volume, extra cloth, of over 600 pages. $2 75. 
WerecommendDr.Barlow'sManualinthewarm- I found it clear, concise, practical, an4s<y»n<i — Sos 

est manner as a most valuable vade-mecum. We | ton Med. and Surg. Journal. 

bave had frequent occasion to consult it, and have 



BLANCHARD & LEA'S MEDICAL 



BUDD (GEORGE), M. D., F. R. S., 

Professor of Medicine in King's College, London. 

ON DISEASES OF THE LIVER. Third American, from the third and 

enlarged London edition. In one very handsome octavo volume, extra cloth, with four beauti- 
fully colored plates, and numerous wood-cuts. pp. 500. $3 00. 



Has fairly established for itself a place among the 
classical medical literature of England. — British 
and Foreign Medico- Chir. Review. 

Dr. Budd's Treatise on Diseases of the Liver is 
now a standard work in Medical literature, and dur- 
ing the intervals which have elapsed between the 
successive editions, the author has incorporated into 



the text the most striking novelties which have cha- 
racterized the recent progress of hepatic physiology 
and pathology: so thatalthough the size of the bool 
is not perceptibly changed, the history of liver dis- 
eases is made more complete, and ia kept upon a level 
with the progress of modern science. It is the best 
work on Diseases of the Liver in any language. — 
London Med. Times and Gazette. 



BUCKNJLL (J. C), M. D., and DANIEL H. TUKE, M. D., 

Medical Superintendent of the Devon Lunatic A3ylum. Visiting Medical Officer to the York Retreat, 

A MANUAL OF PSYCHOLOGICAL MEDICINE; containing the History, 

Nosology, Description, Statistics, Diagnosis, Pathology, and Treatment of INSANITY. With 
a Plate. In one handsome octavo volume, of 538 pages, extra cloth. $3 00. 
The increase of mental disease in its various forms, and the difficult questions to which it is 
constantly giving rise, reader the subject one of daily enhanced interest, requiring on the part oi 
the physician a constantly greater familiarity with this, the most perplexing branch of his profes- 
sion. At the same time there has been for some years no work accessible in this country, present" 
mg the results of recent investigations in the Diagnosis and Prognosis of Insanity, and the greatly 
improved methods of treatment which have done so much in alleviating the condition or restoring 
the health of the insane. To fill this vacancy the publishers present this volume, assured thai 
the distinguished reputation and experience of the authors will entitle it at once to the confidence 
of both student and practitioner. Its scope may be gathered from the declaration of the authors 
that "their aim has been to supply a text book which may serve as a guide in the acquisition oi 
such knowledge, sufficiently elementary to be adapted to the wants of the student, and sufficiently 
modern in its views and explicit in its teaching to suffice for the demands of the practitioner." 



BENNETT (HENRY), M. D. 
A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, 

ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. To which 
is added, a Review of the present state of Uterine Pathology. Fifth American, from the third 
English edition. In one octavo volume, of about 500 pages, extra cloth. $2 00. 

BROWN (ISAAC BAKER), 

Surgeon- Accoucheur to St. Mary's Hospital, &c. 

ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT- 
MENT. With handsome illustrations. One vol. 8vo., extra cloth, pp. 276. $160. 



Mr. Brown has earned for himself a high reputa- 
tion in the operative treatment of sundry diseases 
and injuries to which females are peculiarly subject. 
We can truly say of his work that it is an important 
addition to obstetrical literature. The operative 
suggestions and contrivances which Mr. Brown de- 
scribes, exhibit much practical sagacity and skill, 



and merit the careful attention of every sargeoa- 
aceoucheur.— Association Journal. 

We have no hesitation in recommending this book 
to t.ie careful attention of all surgeons who make 
female complaints a part of their study and practice. 
— Dublin (quarterly Journal. 



BOWMAN (JOHN E.), M.D. 
PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited by C. 

L. Bloxam. Third American, from the fourth and revised English Edition. In one neat volume, 
royal 12mo., extra cloth with numerous illustrations, pp.351. $175. (Now Ready, May, 1863.) 



Of this well-known handbook we may say that 
it retains all iis old simplicity and clearness of ar- 
rangement and description, whilst it has received 
from the able editor those finishing touches which 
the progress of chemistry has rendt red necessary. — 
London Med. Times and Gazette, Nov. 29, 1862. 

Nor is anything hurried over, anything shirked ; 
open the book where you will, you find the same 
careful treatment of the subject manifested, ana the 
best process for the attainment of the particular ob- 
ject in view lucidly detailed and explained. And 

BY THE SAME AUTHOR. 

INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- 

LYSIS. Second American, from the second and revised London edition. With numerous illus- 
trations. In one neat vol., royal 12mo., extra cloth, pp. 298. $125. 



this new edition is not merely a reprint of the last. 
With a laudable desire to keep the book up to tne 
scientific mark of the present age, every improve- 
ment in analytical method has been introduced. Jn 
conclusion, we would only say that, familiar from 
long acquaintance with each page of the former 
issues of this little book, we gladly place beside 
them another presenting so many acceptable im- 
provements and additions.— Dublin Medical Press, 
Jan. 7, 1863. 



BEALE ON THE LAWS OF HEALTH IN RE- 
LATION TO MIND AND BODY. A Series of 
Letters from an old Practitioner to a Patient. In 
one volume, royal 12mo., extra cloth, pp. 296. 
80 cents. 

BUSHNAN'S PHYSIOLOGY OF ANIMAL AND 
VEGETABLE LIFE ; a Popular Treatise on the 
Functions and Phenomena of Organic Life. In 
one handsome royal 12mo. volume, extra cloth, 
with over 100 illustrations, pp.234. 80 cents. 



BUCKLER ON THE ETIOLOGY, PATHOLOGY, 
AND TREATMENT OF FIBRO-BRONCHI- 
TIS AND RHEUxMATIC PNEUMONIA. In 
one 8vo. volume, extra cloth, pp.150. $125. 

BLOOD AND URINE (MANUALS ON). BY 
JOHN WILLIAM GRIFFITH, G. OWEN 
REESE, AND ALFRED MARKWICK. One 
thick volume, royal 12mo., extra cloth, wit& 
plates, pp. 460. $1 25. 

BRODIE'S CLINICAL LECTURES ON SUR- 
GERY. 1 vol. 8 vo. cloth. 350pp. 8125. 



AND SCIENTIFIC PUBLICATIONS. 



BUMSTEAD (FREEMAN JJ M. D., 

Lecturer on Venereal Diseases at the College of Pnysicians and Surgeons, New York, &c. 

THE PATHOLOGY A^D TREATMENT OF VENEREAL DISEASES, 

including the results of recent invesiigat ions upon the subject. With illustrations on wood. In 
one very handsome octavo volume, of nearly 700 pages, extra cloth ; $3 75. 

To sum up all in a few words, this book is one which 
no practising physician or medical student can very 
well afford to do without. — American Med. Times, 
Nov. 2, 1861. 



By far the most valuable contribution to this par- 
ticular branch of practice that has seen the light 
within the lasc score of years. His clear and accu- 
rate descriptions of the various forms of venereal 
disease, and especially the methods of treatment he 
proposes, are worthy of the highest encomium. In 
these respects it is better adapted for the assistance 
of the every-day practitioner than any other with 
which we are acquainted. In variety of methods 
proposed, in minuteness of direction, guided by care- 
lul discrimination of varying forms and complica 
tions, we write down the book as unsurpassed. It 
is a work which should be in the possession of every 
practitioner.— Chicago Med. Journal. Nov. 1861. 

Tne foregoing admirable volume comes to us, em- 
bracing the whole subject of syphilology, resolving 
many a doubt, correcting and confirming many an 
entertained opinion, and in our estimation the best, 
eompletest, fullest monogiaph on this subject in our 
language. As far as the author's labors themselves 
are concerned, we feel it a duty to say that he has 
not only exhausted his subject, but he has presented 
to us, without the slightest hyperbole, the best di- 
gested treatise on these diseases in our language 
He has carried its literature down to the present 
moment, and has achieved his task in a manner 
which cannot but redound to his credit. — British, 
American Journal, Oct. 1561. 

We believe this treatise will come to be regarded 
as high authority in this branch of medical practice, 
and we cordially commend it to the favorable notice 
of our brethren in the profession. For our own part, 
we candidly confess that we have received nany 
new iaeas from its perusal, as well as modified many 
views which we have long, and, as we now think . 
erroneously entertained on the subject of syphilis. 



The whole work presents a complete history of 
venereal diseases, comprising much interesting and 
valuable material that has been spread through mtd- 
ical journals within the last twenty years — the pe- 
riod of many experiments and investigations on the 
subject — the wh'de carefully digested by the aid of 
the author's extensive personal experience, and 
offeied to the profession in an admirable form. Its 
completeness is secured by good plates, which are 
especially full in the anatomy of the genital organs. 
We have examined it with great satisfaction, and 
congratulate the medical profession in America on 
the nationalicy of a work that may fairly be ealled 
original. — Berkshire Med. Journal, Dec. 1861. 

One thing, however, we are impelled to say, that 
we have met with no other book on syphilis, in the 
English language, which gave so full, clear and 
impartial views of the important subjects on wnich 
it treats. We cannot, however, refrain from ex- 
pressing our satisfaction with the full and perspicu- 
ous manner in which the subject has been presented, 
and the careful attencion to minute details, so use- 
ful — not to say indispensable — in a practical treatise. 
In conclusion, if we may be pardoned the use of a 
phrase now become stereotyped, but which we here 
employ in all seriousness and sincerity, we do not 
hesitate to express the opinion that Dr. Bumstead's 
Treatise on Venereal Diseases is a u work without 
which no medical library will hereafter be consi- 
dered complete." — Boston Med. and Surg. Journal, 
Sept. 5, 1861. 



BARCLAY (A. W.), M. D., 

Assistant Physician to St. George's Hospital, &c. 

A MANUAL OF MEDICAL DIAGNOSIS ; being an Analysis of the Signs 

and Symptoms of Disease. Second American from the second and revised London edition. la 

one neat octavo volume, extra cloth, of 451 pages. $2 25. 

The demand for a second edition of this work shows that the vacancy which it attempts to sup- 
ply has been recognized by the profession, and that the efforts of the author to meet the want have 
been successful. The revision which it has enjoj^ed will render it better adapted than before to 
afford assistance to the learner in the prosecution of his studies, and to the practitioner who requires 
a convenient and accessible manual for speedy reference in the exigencies of his daily duties. For 
this latter purpose its complete and extensive Index renders it especially valuable, offering facilities 
for immediately turning to any class of symptoms, or any variety of disease. 

The task of composing such a work is neither an 
easy nor a light one ; but Dr. Barclay has performed 
it in a manner which meets our most unqualified 
approbation. He is no mere theorist; he knows his 



work thoroughly, and in attempting to perform it, 
has not exceeded his powers. — British Med. Journal . 

We venture to predict that the work will be de- 
servedly popular, and soon become, like Watson's 
Practice, an indispensable necessity to the practi- 
tioner. — N. A. Med. Journal. 

An inestimable work of reference for the young 
practitioner and student. — Nashville Med. Journal. 



We hope the volume will have an extensive cir- 
culation, not among students of medicine only, but 
practitioners also. They will never regret a faith- 
ful study of itspages. — Cincinnati Lancet. 

An important acquisition to medical literature. 
It is a work of high merits both from the vast im- 
porcance of the subject upon which it treats, and 
also from the real ability displayed in J ta elabora- 
tion. In conclusion, let us bespeak for this volume 
that attention of every student of our art which it 
so richly deserves — that place in every medical 
library which it can so well adorn .'^Peninsular 
Medical Journal. 



BARTLETT (ELISHA), M. D. 
THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS 

OF THE UNITED STATES. A new and revised edition. By Alonzo Clark , M. D., Prof. 
of Pathology and Practical Medicine in the N. Y. College of Physicians and Surgeons, &c. la. 
one octavo volume, of six hundred pages, extra cloth. Price $3 00. 



It is a work of great practical value and interest, 
containing much that is new relative to the several 
diseases of which it treats, and, with the additions 
of the editor, is fully up to the times. The distinct- 
ive features of the different forms of fever are plainly 
and forcibly portrayed, and the lines of demarcation 
carefully and accurately drawn, and to the Ameri- 
can practitioner is a more valuable and safe guide 
than any work on fever extant. — Ohio Med. and 
Surg. Journal. 

This excellent monograph on febrile disease, has 



stood deservedly high since its first publication. It 
will be seen that it has now reached its fourth edi- 
tion under the supervision of Prof. A. Clark, a gen- 
tleman who, from the nature of his studies and pur- 
suits, is well calculated to appreciate and discuss 
the many intricate and difficult questions in patho- 
logy. His annotations add much to the interest of 
the work, and have brought it well up to the condi- 
tion of the science as it exists at the present day 
in regard to this class of diseases.— Southern Med. 
and Surg. Journal. 



BLANCHARD & LEA'S MEDICAL 



BRANDE (WM. T.) D. C, 

Of her Majesty's Mint, &c. 



and ALFRED S. TAYLOR, M. D., F. R. S. 

Professor of Chemistry and Medical Jurisprudence in 
Guy's Hospital. 

CHEMISTRY. In one handsome 8vo. volume of 696 pages, extra cloth. $3 50. 

{Now Ready, May, 1863.) 

"Having been engaged in teaching Chemistry in this Metropolis, the one for a period of forty, 
and the other for a period of thirty years, it has appeared to us that, in spite of the number of books 
already exiting, there was room for an additional volume, which should be especially adapted for 
the use of students. In preparing such a volume for the press, we have endeavored to bear in 
mind, that the student in the present day has much to learn, and but a short time at his disposal for 
the acquisition of this learning." — Authors' Preface. 

In reprinting this volume, its passage through the press has been superintended by a competent 
chemist, who has sedulously endeavored to secure the accuracy so necessary in a work of this 
nature. No notes or additions have been introduced, but the publishers have been favored by the 
authors with some corrections and revisions of the first twenty-one chapters, which have been duiy 
inserted. 

In so progressive a science as Chemistry, the latest work always has the advantage of presenting 
the subject as modified by the results of the latest investigations and discoveries. That this advan- 
tage has been made the most of, and that the work possesses superior attractions arising from its 
clearness, simplicity of style, and lucid arrangement, are manifested by the unanimous testimony 
of the English medical press. 

It needs no great sagacity to foretell that this book 
will be, literally, the Handbook in Chemistry of the 
student and practitioner. For clearness of language, 
accuracy of description, extent of information, and 
freedom from pedantry and mysticism of modern 
chemistry, no other text-book comes into competition 
■with it. The result is a work which for fulness of 
matter, for lucidity of arrangement, for clearness of 
style, is as yet without a rival. And long will it be 
without a rival. For, although with the necessary 
advance of chemical knowledge addenda will be re- 
quired, there will be little to take away. The funda- 
mental excellences of the book will remain, preserv- 
ing it for years to come, what it now is, the best guide 
to the study of Chemistry yet given to the world. — 
London Lancet, Dec. 20. 1862. 



Most assuredly, time has not abated one whit of the 
fluency, the vigor, and the clearness with which they 
not only have composed the work before us, but have, 
so to say, cleared the ground for it, by hitting right 



and left at the affectation, mysticism, and obscurity 
which pervade some late chemical treatises. Thus 
conceived, and worked out in the most sturdy, com- 
mon sense method, this book gives, in the clearest and 
most summary method possible, all the facts and doc- 
trines of chemistry, with more especial reference to 
the wants of the medical student. — London Medical 
Times and Gazette, Nov. 29, 1S62. 

If we are not very much mistaken, this book will 
occupy a place which none has hitherto held among 
chemists ; for, by avoiding the errors of previous au- 
thors, we have a work which, for its size, is certainly 
the most perfect of any in the English language. 
There are several points to be noted in this volume 
which separate it widely from any of its compeers — 
its wide application, not to the medical student only, 
nor to the student in chemistry merely, but to every 
branch of science, art, or commerce which is in any 
way connected with the domain of chemistry. — 2/0»» 
donMed. Review, Feb. 1863. 



BARWELL (RICHARD,) F- R. C. S., 

Assistant Surgeon Charing Cross Hospital, &c. 

A TREATISE ON DISEASES OF THE JOINTS. Illustrated with engrav- 

ings on wood. In one very handsome octavo volume, of about 500 pages, extra cloth; $3 00. 



At the outset we may state that the work is 
worthy of much praise, and bears evidence of much 
thoughtful and careful inquiry, and here and there 
of no slight originality. We have already carried 
this notice further than we intended to do, but not 
to the extent the work deserves. We can only add, 
that the perusal of it has afforded us great pleasure. 
The author has evidently worked very hard at his 
subject, and his investigations into the Physiology 
and Pathology of Joints have been carried on in a 
manner which entitles him to be listened to with 
attention and respect. We must not omit to men- 
tion the very admirable plates with which the vo- 
lume is enriched. We seldom meet with such strik- 



ing and faithful delineations of disease. — London 
Med. Times and Gazette, Feb. 9, 1861. 

This volume will be welcomed, as the record of 
much honest research and careful investigation into 
the nature and treatment of a most important class 
of disorders. We cannot conclude this notice of a 
valuable and useful book without calling attention 
to the amount of bona fide work it contains. It is no 
slight matter for a volume to show laborious inves- 
tigation, and at the same time original thought, on 
the part of its author, whom we may congratulate 
on the successful completion of his arduous task. — 
London Lancet, March 9, 1861. 



CARPENTER (WILLIAM BJ, M. D., F. R. S., &c, 

Examiner in Physiology and Comparative Anatomy in the University of London. 

THE MICROSCOPE AND ITS REVELATIONS. With an Appendix con- 
taining the Applications of the Microscope to Clinical Medicine, &c. By F. G. Smith, M. D, 
Illustrated by four hundred and thirty-four beautiful engravings on wood. In one large and very 
handsome octavo volume, of 724 pages, extra cloth, $4 50. 

The great importance of the microscope as a means of diagnosis, and the number of microsco- 
pists who are also physicians, have induced the American publishers, with the author's approval, to 
add an Appendix, carefully prepared by Professor Smith, on the applications of the instrument to 
clinical medicine, together with an account of American Microscopes, their modifications and 
accessories. This portion of the work is illustrated with nearly one hundred wood-cuts, and, it is 
hoped, will adapt the volume more particularly to the use of the American student. 
Those who are acquainted with Dr. Carpenter's 

firevious writings on Animal and Vegetable Physio- 
ogy , will fully understand how vast a store of know- 
ledge he is able to bring to bear upon so comprehen- 
sive a subject as the revelations of the microscope ; 
and even those who have no previous acquaintance 
with the construction or uses of this instrument, 
will find abundance of information conveyed in clear 
and simple language.— Med. Times and Gazette. 



The additions by Prof. Smith give it a positive 
claim upon the profession, for which we doubt not 
he will receive their sincere thanks. Indeed, we 
know not where the student of medicine will find 
such a complete and satisfactory collection of micro- 
scopic facts bearing upon physiology and practical 
medicine as is contained in Prof. Smith's appendix; 
and this of itself, it seems to us, is fully worth the 
cost of the volume. — Louisville Medical Review. 



AND SCIENTIFIC PUBLICATIONS, 



CARPENTER (WILLIAM B.), M. D. f F. R. S., 

Examiner in Physiology and Comparative Anatomy in the University 01" London. 

PRINCIPLES OF HUMAN PHYSIOLOGY ; with their chief applications to 

Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from 
the last and revised London edition. With nearly three hundred illustrations. Edited, with addi- 
tions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the Pennsyl- 
vania Medical College, &c. In one very large and beautiful octavo volume, of about nine hundred 
large pages, handsomely printed and strongly bound in leather, with raised bands. $4 75, 



For upwards of thirteen years Dr. Carpenter's 
work has been considered by the profession gene- 
rally, both in this country and England, as the most 
valuable compendium on the subject of physiology 
in our language. This distinction it owes to the high 
attainments and unwearied industry of its accom- 

filished author. The present edition (which, like the 
ast American one, was prepared by the author him- 
self), is the result of such extensive revision, that it 
may almost be considered a new work. We need 
hardly say, in concluding this brief notice, that while 
the work is indispensable to every student of medi- 
cine in this country, it will amply repay the practi- 
tioner for its perusal by the interest and value of its 
contents. — Boston Med. and Surg. Journal. 

This is a standard work — the text-book used by all 
medical students who read the English language. 
It has passed through several editions in order to 
keep pace with the rapidly growing science of Phy- 
siology. Nothing need be said in its praise, for its 
merits are universally known; we have nothing to 
say of its defects, for they only appear where the 
science of which it treats is incomplete. — Western 
Lancet. 

The most complete exposition of physiology which 
any language can at present give. — Brit, and For. 
Med.-Chirurg. Review. 

The greatest, the most reliable, and the best book 
on the subject which we know of in the English 
Language. — Stethoscope. 



To eulogize this great work would be superfluous . 
We should observe, however, that in this edition 
the author has remodelled a large portion of the 
former, and the editor has added much matter of in- 
terest, especially in the form of illustrations. We 
may confidently recommend it as the most complete 
work on Human Physiology in our language. — 
Southern Med. and Surg. Journal. 

The most complete work on the science in our 
language. — Am. Med. Journal. 

The most complete work now extant in our lan- 
guage. — N. O. Med. Register. 

The best text-book in the language on this ex- 
tensive subject. — London Med. Times. 

A complete cyclopadia of this branch of science. 
— JV. Y. Med. Times. 

The profession of this country, and perhaps also 
of Europe, have anxiously and for some time awaited 
the announcement of this new edition of Carpenter's 
Human Physiology. His former editions have for 
many years been almost the only text-book on Phy- 
siology in all our medical schools, and its circula- 
tion among the profession has been unsurpassed by 
any work in any department of medical science. 

It is quite unnecessary for us to speak of this 
work as its merits would justify. The mere an- 
nouncement of its appearance will afford the highest 
pleasure to every student of Physiology, while its 
perusal will be of infinite service in advancing 
physiological science. — Ohio Med. and Surg. Journ , 



BY THE SAME AUTHOR. 

ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- 
LOGICAL ANATOMY. Second American, from a new and revised London edition. With 
one hundred and ninety illustrations. In one very handsome octavo volume, leather, pp. 566. 
$3 00. 

In publishing the first edition of this work, its title was altered from that of the London volume, 
by the substitution of the word " Elements" for that of " Manual," and with the author's sanction 
the title of "Elements" is still retained as being more expressive of the scope of the treatise. 



BY THE SAME AUTHOR. 



PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New American, from 

the Fourth and Revised London edition. In one large and handsome octavo volume, with over 
three hundred beautiful illustrations, pp. 752. Extra cloth, $5 25. 



This book should not only be read but thoroughly 
studied by every member of the profession. None 
are too wise or old, to be benefited thereby. But 
especially to the younger class would we cordially 
commend it as best fitted of any work in the English 
language to qualify them for the reception and com- 
prehension of those truths which are daily being de- 
veloped in physiology. — Medical Counsellor. 

Without pretending to it, it is an encyclopedia of 
the subject, accurate and complete in all respects — 
a truthful reflection of the advanced state at which 
the science has now arrived. — Dublin Quarterly 
Journal of Medical Science. 

A truly magnificent work — in itself a perfect phy- 
siological study. — Ranking* s Abstract. 

This work stands without its fellow. It is one 
few men in Europe could have undertaken ; it is one 



no man, we believe, could have brought to so suc- 
cessful an issue as Dr. Carpenter. It required for 
its production a physiologist at once deeply read in 
the labors of others, capable of taking a general, 
critical, and unprejudiced view of those labors, and 
of combining the varied, heterogeneous materials at 
his disposal, so as to form an harmonious whole. 
We feel that this abstract can give the reader a very 
imperfect idea of the fulness of this work, and no 
idea of its unity, of the admirable mar ner in which 
material has been brought, from the most various 
sources, to conduce to its completeness of the lucid- 
ity of the reasoning it contains, or of the clearness 
of language in which the whole is clothed. Not the 
profession only, but the scientific world at large, 
must feel deeply indebted to Dr. Carpenter for this 
great work. It must, indeed, add largely even to 
his high reputation. — Medical Times. 



BY THE same author. (Preparing.) 

PRINCIPLES OF GENERAL PHYSIOLOGY, INCLUDING ORGANIC 

CHEMISTRY AND HISTOLOGY. With a General Sketch of the Vegetable and Animal 
Kingdom. In one large and very handsome octavo volume, with several hundred illustrations. 

BY THE SAME AUTHOR. 

A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH 

AND DISEASE. New edition, with a Preface by D. F. Condie, M. D., and explanations of 
scientific words. In one neat 12mo. volume, extra cloth, pp. 178. 50 cents. 



8 



BLANCHARD & LEA'S MEDICAL 



CONDIE (D. F.), M. D., &c. 
A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fifth 

edition, revised and augmented. In one large volume, 8vo., extra cloth, of over 750 pages. $3 25. 

In presenting a new and revised edition of this favorite work, the publishers have only to state 
that the author has endeavored to render it in every respect "a complete and faithful exposition of 
the pathology and therapeutics of the maladies incident to the earlier stages of existence — a full 
and exact account of the diseases of infancy and childhood." To accomplish this he has subjected 
the whole work to a careful and thorough revision, rewriting a considerable portion, and adding 
several new chapters. In this manner it is hoped that any deficiencies which may have previously 
existed have been supplied, that the recent labors of practitioners and observers have been tho- 
roughly incorporated, and that in every point the work will be found to maintain the high reputation 
it has enjoyed as a complete and thoroughly practical book of reference in infantile affections. 

A few notices of previous editions are subjoined. 

Dr. Condie's scholarship, acumen, industry, and 
practical sense are manifested in this, as in all his 
numerous contributions to science. — Dr. Holmes's 
Report to the American Medical Association. 



Taken as a whole, in our judgment, Dr. Condie's 
Treatise is the one from the perusal of which the 
practitioner in this country will rise with the great- 
est satisfaction.— Western Journal of Medicine and 
Surgery. 

One of the best works upon the Diseases of Chil- 
dren in the English language. — Western Lancet. 

We feel assured from actual experience that nc 
physician's library can be complete without a copy 
of this work. — N. Y. Journal of Medicine. 

A veritable psediatric encyclopaedia, and an honor 
t@ American medical literature. — Ohio Medical and 
Surgical Journal. 

We feel persuaded thatthe American medical pro- 
fession will soon regard it not only as a very good, 
but as the very best "Practical Treatise on the 
Diseases of Children." — American Medical Journal 

In the department of infantile therapeutics, the 
work of Dr. Condie is considered one of the best 
which has been published in the English language. 
— The Stethoscope. 



We pronounced the first edition to be the best 
work on the diseases of children in the English 
language, and, notwithstanding all that has been 
published, we still regard it in that light. — Medical 
Examiner. 

The value of works by native authors on the dis- 
eases which the physician is called upon to combat, 
will be appreciated by all ; and the work of Dr. Coe- 
die has gained for itself the character of a safe guide 
for students, and a useful work for consultation by 
those engaged in practice. — N. Y. Med. Times. 

This is the fourth edition of this deservedly popu- 
lar treatise. During the interval since the last edi- 
tion, it has been subjected to a thorough revision 
by the author; and all new observations in the 
pathology and therapeutics of children have beea 
included in the present volume. As we said before, 
we do not know of a better book on diseases of chil- 
dren, and to a large part of its recommendations we 
yield an unhesitating concurrence. — Buffalo Med. 
Journal. 

Perhaps the most full and complete work now be- 
fore the profession of the United States; indeed, w© 
may say in the English language. It is vastly supe- 
rior to most of its predecessors. — Transylvania Med, 
Journal . 



CHRISTISON (ROBERT), M. D., V. P. R. S. E., &c. 
A DISPENSATORY; or. Commentary on the Pharmacopoeias of Great Britain 

and the United States ; comprising the Natural History, Description, Chemistry, Pharmacy, Ac- 
tions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- 
proved, with a Supplement containing the most important New Remedies. With copious Addi- 
tions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M. Do 
In one very large and handsome octavo volume, extra cloth, of over 1000 pages, $3 50. 



COOPER (BRANSBY B.), F. R. S. 
LECTURES ON THE PRINCIPLES AND PRACTICE OF SURQERY. 

In one very large octavo volume, extra cloth, of 750 pages. $3 00. 



COOPER ON DISLOCATIONS AND FRAC- 
TURES OF THE JOINTS— Edited byBRANSBT 
B. Cooper, F. R. S., &c. With additional Ob- 
servations by Prof. J. C. Warren. A new Ame- 
rican edition. In one handsome octavo volume, 
extra cloth, of about 500 pages, with numerous 
illustrations on wood. $3 25. 

COOPER ON THE ANATOMY AND DISEASES 
OF THE BREAST, with twenty-five Miscellane- 
ous and Surgical Papers. One large volume, im- 
perial 8vo., extra cloth, with 252 figures, on 36 
plates. $2 50. 

COOPER ON THE STRUCTURE AND DIS- 
EASES OF THE TESTIS, AND ON THE 
THYMUS GLAND. One vol. imperial 8vo., ex- 
tra cloth, with 177 figures on 29 plates. $2 00. 



COPLAND ON THE CAUSES, NATURE, AND 
TREATMENT OF PALSY AND APOPLEXY. 

In one volume, royal 12mo., extra cloth, pp.326, 
80 cents. 

CLYMER ON FEVERS; THEIR DIAGNOSIS, 
PATHOLOGY, AND TREATMENT. In on© 
octavo volume, leather, of 600 pages.'- %\ 50. 

COLOMBAT DE L'ISERE ON THE DISEASES 
OF FEMALES, and on the special Hygiene of 
their Sex. Translated, with many Notes and Ad- 
ditions, by C. D. Meigs, M. D. Second edition, 
revised and improved. In one large volume, oc- 
tavo, leather, with numerous wood-cuts. pp. 720. 
$3 50. 



CARSON (JOSEPH), M. D., 

Professor of Materia Medica and Pharmacy in the University of Pennsylvania. 

SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA MEDICA 

AND PHARMACY, delivered in the University of Pennsylvania. 



CURLING (T. B.), F.R.S., 
Surgeon to the London Hospital, President of the Hunterian Society, &o. 

A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, SPERMA- 

TIG CORD, AND SCROTUM. - Second American, from the second and enlarged English edi- 
tion, in one handsome octavo vo ume, extra cloth, with numerous illustrations, pp. 420. $2 00 



AND SCIENTIFIC PUBLICATIONS. 



CHURCHILL (FLEETWOOD), M. D., M. R. I. A. 
ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American 

from the fourth revised and enlarged London edition. With Notes and Additions, by D. Francis 
Condie, M. D., author of a "Practical Treatise on the Diseases of Children," &c. With 194 
illustrations. In one very handsome octavo volume, leather, of nearly 700 large pages. $3 75. 
This work has been so long an established favorite, both as a text-book for the learner and as a 
reliable aid in consultation ior the practitioner, that in presenting a new edition it is only necessary 
to call attention to the very extended improvements which it has received. Having had the benefit 
of two revisions by the author since the last American reprint, it has been materially enlarged, and 
Dr. Churchill's well-known conscientious industry is a guarantee that every portion has been tho- 
roughly brought up with the latest results of European investigation in all departments of the sci- 
ence and art of obstetrics. The recent date of the last Dublin edition has not left much of novelty 
for the American editor to introduce, but he has endeavored to insert whatever has since appeared, 
together with such matters as his experience has shown him would be desirable for the American 
student, including a large number of illustrations. With the sanction of the author he has added 
in the form of an appendix, some chapters from a little "Manual for Mid wives and Nurses," re- 
cently issued by Dr. Churchill, believing that the details there presented can hardly fail to prove of 
advantage to the junior practitioner. Tne result of all these additions is that the work now con- 
tains fully one-half more matter than the last American edition, with nearly one-half more illus- 
trations, so that notwithstanding the use of a smaller type, the volume contains almost two hundred 
pages more than before. 

No effort has been spared to secure an improvement in the mechanical execution of the work 
equal to that which the text has received, and the volume is confidently presented as one of the 
handsomest that has thus far been laid before the American profession; while the very low price 
at which it is offered should secure for it a place in every lecture-room and on every office table. 

Were we reduced to the necessity of having but 
me work on midwifery, and permitted to choose , 
wq would unhesitatingly take Churchill. — Western 



A better book in which to learn these important 
points we have not met than Dr. Churchill's. Every 
page of it is full of instruction; the opinion of all 
writers of authority is given on questions of diffi- 
culty, as well as the directions and advice of the 
learned auttior himself, to which he adds the result 
of statistical inquiry, putting statistics in their pro- 
per place and giving them their due weight, and no 
more. We have never read a book more free from 
professional jealousy than Dr. Churchill's. It ap- 
pears to be written with the true design of a book on 
medicine, viz : to give all that is known on the sub- 
ject of which he treats, both theoretically and prac- 
tically, and to advance such opinions of his own as 
he believes will benefit medical science, and insure 
the safety of the patient. We have said enough to 
convey to the profession that this book of Dr. Cliur- 
chill's is admirably suited for a book of reference 
for the practitioner, as well as a text-book for the 
student, and we hope it may be extensively pur- 
chased amongst our readers. To them we most 
strongly recommend it. — Dublin Medical Press. 

To bestow praise on a book that has received such 
marked approbation would be superfluous. We need 
only say, therefore, that if the first edition was 
thought worthy of a favorable reception by the 
medical public, we can confidently affirm that this 
will be found much more so. The lecturer, the 
practitioner, and the student, may all have recourse 
to its pages, and derive from their perusal much in- 
terest and instruction in everything relating to theo- 
retical and practical midwifery. — Dublin Quarterly 
Journal of Medical Science. 

A work of very great merit, and such as we can 
confidently recommend to the study of every obste- 
tric practitioner. — London Medical Gazette. 

Few treatises will be found better adapted as £ 
text-book for the student, or as a manual for th< 
frequent consultation of the young practitioner.— 
American Medical Journal. 



and Surg. Journal. 

It is impossible to conceive a more useful and 
ilegant manual than Dr. Churchill's Practice of 
Midwifery. — Provincial Medical Journal. 

Certainly, in our opinion, the very best work on 
he subject which exists. — N. Y. Annalist. 

No work holds a higher position, or is more de- 
serving of being placed in the hands of the tyro, 
the advanced student, or the practitioner. — Medical 
Examiner. 

Previous editions have been received with mark- 
ed favor, and they deserved it; but this, reprinted 
from a very late Dublin edition, carefully revised 
and brought up by the author to the present time, 
does present an unusually accurate and able expo- 
sition of every important particular embraced in 
the department of midwifery. * * The clearness, 
directness, and precision of its teachings, together 
with the great amount of statistical research which 
its text exhibits, have served to place it already in 
the foremost rank of works in this department of re- 
medial science. — N. O. Med. and Surg. Journal. 

In our opinion, it forms one of the best if not the 
very best text-book and epitome of obstetric science 
which we at present possess in the English lan- 
guage. — Monthly Journal of Medical Science. 

The clearness and precision of style in which it is 
written, and the greatamount of statistical research 
which it contains, have served to place it in the first 
rank of works in this departmentof medical science. 
— N. Y. Journal of Medicine. 

This is certainly the most perfect system extant. 
It is the best adapted for the purposes of a text- 
book, and that which he whose necessities confine 
iim to one book, should select in preference to all 
others. — Southern Medical and Surgical Journal. 

by the same author. {Lately Published.) 

ON THE DISEASES OF INFANTS AND CHILDREN. Second American 

Edition, revised and enlarged by the author. Edited, with Notes, by W. V. Keating, M. D. In 

one large and handsome volume, extra cloth, of over 700 pages. $3 25. 

In preparing this work a second time for the American profession, the author has spared no 
labor in giving it a very thorough revision, introducing several new chapters, and rewriting others, 
while every portion of the volume has been subjected to a severe scrutiny. The efforts of the 
American editor have been directed to supplying such information relative to matters peculiar 
to this country as might have escaped the attention of the author, and the whole may, there- 
fore, be safely pronounced one of the most complete works on the subject accessible to the Ame- 
rican Profession. By an alteration in the size of the page, these very extensive additions have 
been accommodated without unduly increasing the size of the work. 

BY THE SAME AUTHOR. 

ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- 
CULIAR TO WOMEN. Selected from the writings of British Authors previous to the close of 
the Eight^ntk Century. In one neat octavo volume, extra eloth, of about 450 pages. $2 50, 



10 BLANCHARD & LEA'S MEDICAL 



CHURCHILL (FLEETWOOD), M. D., M. R. I. A., &c 
ON THE DISEASES OF WOMEN; including those of Pregnancy and Child- 
bed. A new American edition, revised by the Author. With Notes and Additions, by D Fran- 
cis Condie, M. D., author oi « A Practical Treatise on the Diseases of Children." With nume- 
rous illustrations. In one large and handsome octavo volume, extra cloth, of 768 pages. $3 00. 
This edition of Dr. Churchill's very popular treatise may almost be termed a new work so 
thoroughly has he revised it in every portion. It will be found greatly enlarged, and completely 
brought up to the most recent condition of the subject, while the very handsome series of illustra- 
tions introduced, representing such pathological conditions as can be accurately portrayed, present 
a novel feature, and afford valuable assistance to the young practitioner. Such additions as ap- 
peared desirable for the American student have been made by the editor, Dr. Condie, while a 
marked improvement in the mechanical execution keeps pace with the advance in all other respects 
which the volume has undergone, while the price has been kept at the former very moderate rate. 

It comprises, unquestionably, one of the most ex- 
act and comprehensive expositions of the present 
state of medical knowledge in respect to the diseases 



of women that has yet been published. — Am. Journ 
Med. Sciences. 

This work is the most reliable which we possess 
on this subject; and is deservedly popular with the 
profession. — Charleston Med. Journal, July, 1857. 

We know of no author who deserves that appro- 
bation, on "the diseases of females," to the same 



extent that Dr. Churchill does. His, indeed, is the 
only thorough treatise we know of on the subject $ 
and it may be commended to practitioners and stu- 
dents as a masterpiece in its particular department, 
— Tht Western Journal of Medicine and Surgery. 

As a comprehensive manual for students, or a 
work of reference for practitioners, it surpasses any 
other that has ever issued on the same subject from 
the British press. — Dublin Quart. Journal. 



DICKSON (S. H.), M. D. 3 

Professor of Practice of Medicine in the Jefferson Medical College, Philadelphia. 

ELEMENTS OF MEDICINE; a Compendious View of Pathology and Thera- 
peutics, or the History and Treatment of Diseases. Second edition, revised. In one large and 
handsome octavo volume, oi 750 pages, extra cloth. $3 75. 

The steady demand which has so soon exhausted the first edition of this work, sufficiently shows 
that the author was not mistaken in supposing that a volume of this character was needed — aa 
elementary manual of practice, which should present the leading principles of medicine with the 
practical results, in a condensed and perspicuous manner. Disencumbered of unnecessary detail 
and fruitless speculations, it embodies what is most requisite for the student to learn, and at the 
same time what the active practitioner wants when obliged, in the daily calls of his profession, to 
refresh his memory on special points. The clear and attractive style of the author renders the 
whole easy of comprehension, while his long experience gives to his teachings an authority every- 
where acknowledged. Few physicians, indeed, have had wider opportunities for observation and 
experience, and few, perhaps, have used them to better purpose. As the result of a long life de- 
voted to study and practice, the present edition, revised and brought up to the date of publication 
will doubtless maintain the reputation already acquired as a condensed and convenient Americas 
text-book on the Practice of Medicine. 



DRUITT (ROBERT), M.R. C.S., &e. 
THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new 

and revised American from the eighth enlarged and improved London edition. Illustrated witia 

four hundred and thirty-two wood-engravings. In one very handsomely printed octavo volume, 

leather, of nearly 700 large pages. $3 75. 

A work which like Drtjitt's Surgery has for so many years maintained the position of a lead- 
ing favorite with all classes of the profession, needs no special recommendation to attract attention 
to a revised edition. It is only necessary to state that the author has spared no pains to keep the 
work up to its well earned reputation of presenting in a small and convenient compass the latest 
condition of every department of surgery, considered both as a science and as an art; and that the 
services of a competent American editor have been employed to introduce whatever novelties may 
have escaped the author's attention, or may prove of service to the American practitioner. As 
several editions have appeared in London since the issue of the last American reprint, the volume 
has had the benefit of repeated revisions by the author, resulting in a very thorough alteration and 
improvement. The extent of these additions may be estimated from the fact that it now contains 
about one-third more matter than the previous American edition, and that notwithstanding the 
adoption of a smaller type, the pages have been increased by about one hundred, while nearly two 
hundred and fifty wood-cuts have been added to the former list of illustrations. 

A marked improvement will also be perceived in the mechanical and artistical execution of the 
work, which, printed in the best style, on new type, and fine paper, leaves little to be desired as 
regards external finish; while at the very low price affixed it will be found one of the cheapest 
Volumes accessible to the profession. 



This popular volume, now a most comprehensive 
work on surgery, has undergone many corrections, 
improvements, and additions, and the principles and 
the practice of the art have been brought down to 
the latest record and observation. Of the operations 
in surgery itis impossible to speak too highly. The 
descriptions are so clear and concise, and the illus- 
trations so accurate and numerous, that the student 
can have no difficulty, with instrument in hand, and 



nothing of real practical importance has been omit- 
ted ; it presents a faithful epitome of everything re- 
lating t » surgery up to the present hour. It is de- 
servedly a popular manual, both with the student 
and practitioner. — London Lancet, Nov. 19, 1859. 

In closing this brief notice, we recommend as cor- 
dially as ever this most; useful and comprehensive 
hand-book. It must prove a vast assistance, noi 



book by his side, over the dead body, in obtaining | on\y *othe student of surgery, but also to the busy 



a proper knowledge and sufficient tact in this much 
neglected department of medical education. — British 
and Foreign Medico-Chirurg . Review, Jan. I860. 

In the present edition the author has entirely re- 
written many of the chapters, and has incorporated 

the various improvements and additions in modern j or practitioner could desire. — Dublin Qua-rUrly 
aurgery. On carefully going over it : we find that | Journal of Med. Sciences^ Nov. 1853, 



practitioner whc may not have the leisure to devote 
himself to the study of more lengthy volumes — • 
London Med. Times and Gazette, Oct. 22, 1859. 

In a word, this eighth edition of Dr. Druitt's 
Manual of Surgery is all that the surgical student 



AND SCIENTIFIC PUBLICATIONS. 



11 



DALTON, JR. (J. C), M . D. 

Professor of Physiology in the College of Physicians, New York. 

A TREATISE ON HUMAN PHYSIOLOGY, designed for the use of Students 

and Practitioners of Medicine. Second edition, revised and enlarged, with two hundred and 

seventy-one illustrations on wood. In one very beautiful octavo volume, of 700 pages, extra 

cloth, $4 00 ; leather, raised bands, $4 50. 

The general favor which has so soon exhausted an edition of, this work has afforded the author 
an opportunity in its revision of supplying the deficiencies wtiich existed in the former volume. 
This has caused the insertion of two new chapters — one on the Special Senses, the other on Im- 
bibition, Exhalation, and the Functions of the Lymphatic System — besides numerous additions of 
smaller amount scattered through the work, and a general revision designed to bring it thoroughly 
up to the present condition of the science with regard to all points which may be considered as 
definitely settled. A number of new illustrations has been introduced, and the work, it is hoped, 
in its improved form, may continue to command the confidence of those for whose use it is in- 
tended. 

It will be seen, therefore, that Dr. Dalton's best i own original views and experiments, together with 
efforts have been directed towards perfecting his a desire to supply what he considered some deficien- 
work. The additions are marked by the same fea- i cies in the first edition, have already made the pre- 
tures which characterize the remainder of the vol- i sent one a necessity, and it will no doubt be even 
ume, and render it by far the most desirable text- \ more eagerly sought for than the first. That it is 
book on physiology to place in the hands of the ! not merely a reprint, will be seen from the author' 
student which, so far as we are aware, exists in 
the English language, or perhaps in any other. We 



int, will i 
statement of the following principal additions and 
alterations which he has made. The present, like 
the first edition, is printed in the highest style of the 
printer's art, and the illustrations are truly admira- 
ble tor their clearness in expressing exactly what 
their author intended. — Boston Medical and Surgi- 
cal Journal, March 28, 1861. 



iherefo re have no hesitation in recommending Dr. j 

Dalton's book for the classes for which it is intend- j 

ed, satisfied as we are that it is better adapted to , 

their use than any other work of the kind to which 

they have access.— American Journal of the Med. j 

Sciences, April, 1861. • r ' -. . , . :.■'■ ,' ,..,. 

' : , ! It is unnecessary to give a detail of the additions; 

It is, therefore, no disparagement to the many j suffice it to say, that they are numerous and import- 
books upon physiology, most excellent in their day, ant, and such as will render the work still more 
to say that Dalton's is the only one that gives us the j valuable and acceptable to the profession as a learn- 
science as it was known to the best philosophers ! ed and original treatise on this all-important branch 
throughout the world, at the beginning of the cur- ' of medicine. All that was said in commendation 
rent year. It states in comprehensive but concise | of the getting up of the first edition, and the superior 
diction, the facts established by experiment, or I style of the illustrations, apply with equal force to 
other method of demonstration, and details, in an i this. No better work on physiology can be placed 
understandable manner, how it is done, but abstains in the hand of the student. — St. Louis Medical and 
from the discussion of unsettled or theoretical paints, j Surgical J ournal , May , 1861. 

Herein it is unique; and these characteristics ren- These additions whlle testifying to the learning 
der it a text-book without a rival, for those who and indaBtry of the aut hor, render the book exeeed- 
desire to study physiological science as it is known ! ingly useful as the most complete expose of a sci- 
fco its most successful cultivators And it isphysi- ; enc of wMch Dr . Dalton is doubtless the ablest 
ology thus presented that lies at the foundation of ■ representative on this side of the Atlantic— New 
correct pathological knowledge; and this m turn is ! Orleans Med. Times, May, 1861. 
the basis of rational therapeutics ; so that patholo- . , .... ' . . J \ 

gy, in faet, becomes of prime importance in the , A second edition of this deservedly popular work 
proper discharge of our every-day practical duties. ; having been called for in the short space of two 



— Cincinnati Lancet, May, 1861. 

Dr. Dalton needs no word of praise from us. He 
is universally recognizea as among the first, if not 
the very first, of American physiologists now living. 
The first edition of his admirable work appeared but 
two years since, and the advance of science, his 



years, the author has supplied deficiencies, which 
existed in the former volume, and has thus more 
completely fulfilled his design of presenting to the 
profession a reliable and precise text- book, and one 
which we consider the best outline on the subject 
of which it treats, in any language. — N. American 
Medico-C hirurg . Review, May, 1861. 



DUNGL1SON, FORBES, TWEEDIE, AND CONOLLY. 
THE CYCLOPEDIA OF PRACTICAL MEDICINE: comprising Treatises on 

the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women 
and Children, Medical Jurisprudence, &c. &c. In four large super-royal octavo volumes, of 
3254 doubie-columned pages, strongly and handsomely bound, with raised bands. $12 00. 
*#* This work contains no less than four hundred and eighteen distinct treatises, contributed by 

sixty-eight distinguished physicians, rendering it a complete library of reference for the country 

practitioner. 

The editors are practitioners of established repu- 
tation, and the list of contributors embraces many 
of the most eminent professors and teachers of Lon- 
don, Edinburgh, Dublin, and Glasgow. It is, in- 
deed, the great merit ol this work that the principal 
articles have been furnished by practitioners who 
have not only devoted especial attention to the dis- 
eases about which they have written, but have 
also enjoyed opportunities for an extensive practi- 
cal acquaintance with them and whose reputation 
carries the assurance of their competency justly to 
appreciate the opinions ol others, while it stamps 
their own doctrines with high and just authority.-^ 
American Medical Journal. 



The most complete work on Practical Medicine 
extant; or, at least, in our language. — Buffalo 
Medical and Surgical Journal. 

For reference, it is above all price to every prac- 
titioner. — Western Lancet. 

One of the most valuable medical publications of 
the day — as a work of reference it is invaluable. — 
Western Journal of Medicine and Surgery. 

It has been to us, both as learner and teacher, a 
work for ready and frequent reference, one in which 
modern English medicine is exhibited in the most 
tdvantageous light. — Medical Examiner. 



DEWEES'S COMPREHENSIVE SYSTEM OF 
MIDWIFERY. Illustrated by occasional cases 
and many engravings. Twelfth edition, with the 
author's last improvements and corrections In 
one octavo volume, extra cloth , of 600 pages. $3 20 . 

BEWEES'S TREATISE ON THE PHYSICAL 



AND MEDICAL TREATMENT OF CHILD 
REN. The last edition. In one volume, octavo, 
extra cloth, 548 pages. $2 80 

DEWEES'S TREATISE ON THE DISEASES 
OF FEMALES. Tenth edition. In one volume, 
octavo extra eloth, 532 pages, with plates. S3 00, 



12 



BLANCHARD & LEA'S MEDICAL 



DUNGLISON (ROBLEY), M. D. 8 

Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. 

NEW AND ENLARGED EDITION. 
MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise 

Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene^ 
Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, Dentistry j 
&c. Notices of Climate and oft Mineral Waters; Formulae for Officinal, Empirical, and Dietetic 
Preparations, &c. With French and other Synonymes. Revised and very greatly enlarged. 
In one very large and handsome octavo volume, of 992 double-columned pages, in small type; 
strongly bound in leather. Price $4 00. 

Especial care has been devoted in the preparation of this edition to render it in every respect 
worthy a continuance of the very remarkable favor which it has hitherto enjoyed. The rapid 
sale of Fifteen large editions, and the constantly increasing demand, show that it is regarded by 
the profession as the standard authority. Stimulated by this fact, the author has endeavored in the 
present revision to introduce whatever might be necessary " to make it a satisfactory and desira- 
ble — if not indispensable — lexicon, in which the student may search without disappointment fo? 
every term that has been legitimated in the nomenclature of the science." To accomplish this, 
large additions have been found requisite, and the extent of the author's labors may be estimated 
from the fact that about Six Thousand subjects and terms have been introduced throughout, ren- 
dering the whole number of definitions about Sixty Thousand, to accommodate which, the num- 
ber of pages has been increased by nearly a hundred, notwithstanding an enlargement in the siae 
of the pag-e. The medical press, both in this country and in England, has pronounced the work in- 
dispensable to all medical students and practitioners, and the present improved edition will not lose 
that enviable reputation. 

The publishers have endeavored to render the mechanical execution worthy of a volume of such 
universal use in daily reference. The greatest care has been exercised to obtain the typographical 
accuracy so necessary in a work of the kind. By the small but exceedingly clear type employed, 
an immense amount of matter is condensed in its thousand ample pages, while the binding will be 
found strong and durable. With all these improvements and enlargements, the price has been kepi 
at the former very moderate rate, placing it within the reach of all. 



This work, the appearance of the fifteenth edition 
of which, it has become our duty and pleasure to 
announce, is perhaps the most stupendous monument 
of labor and erudition in medical literature. One 
would hardly suppose after constant use of the pre- 
ceding editions, where we have never failed to find 
a sufficiently full explanation of ever) medical term, 
that in this edition "about six thousand subjects 
and terms have been added," with a careful revision 
and correction of the entire work. It is only neces- 
sary to announce the advent of this edition to make 
it occupy the place of the preceding one on the table 
of every medical man, as it is without, doubt the best 
and most comprehensive work of the kind which has 
ever appeared. — Buffalo Med. Journ., Jan. 1858. 

The work is a monument of patient research, 
skilful judgment, and vast physical labor, that will 
perpetuate the name of the author more effectually 
than any possible device of stone or metal. Dr. 
Dunglison deserves the thanks not only of the Ame- 
rican profession, but of the whole medical world. — 
North Am. Medico-Chir. Review., Jan. 1858. 

A Medical Dictionary better adapted for the wants 
of the profession than any other with which we are 
acquainted, and of a character which places it far 
above comparison and competition.— Am. Journ. 
Med. Sciences, Jan. 1858. 

We need only say, that the addition of 6,000 new 
terms, with their accompanying definitions, may be 
said to constitute a new work, by itself. We have 
examined the Dictionary attentively, and are most 
happy to pronounce it unrivalled of its kind. The 
erudition displayed, and the extraordinary industry 
which must have been demanded, in its preparation 
and perfection, redound to the lasting credit of its 
author, and have furnished us with a volume indis- 
pensable at the present day, to all who would find 
themselves au niveau with the highest standards of 
medical information. — Boston Medical and Surgical 
Journal, Dec. 31, 1857. 

Good lexicons and encyclopedic work3 generally, 
are the most labor-saving contrivances which lite- 
rary men enjoy ; and the labor which is required to 
produce them in the perfect manner of this example 
is something appalling to contemplate. The author 



tells us in his preface that he has added about six 
thousand terms and subjects to this edition, which, 
before, was considered universally as the best worS 
of the kind in any language. — Silliman's Journal, 
March, 1858. 

He has razed his gigantic structure to the founda- 
tions, and remodelled and reconstructed the entire 
pile. No less than six thousand additional subjects 
and terms are illustrated and analyzed in this new 
edition, swelling the grand aggregate to beyond 
sixty thousand ! Thus is placed before the profes- 
sion a complete and thorough exponent of medical 
terminology , without rival or possibility of rivalry. 
— Nashville Journ. of Med. and Surg., Jan. 1858. 

It is universally acknowledged, we believe, that 
this work is incomparably the best and most com- 
plete Medical Lexicon in the English language. 
The amount of labor which the distinguished author 
has bestowed upon it is truly wonderful, and the 
learning and research displayed in its preparation 
are equally remarkable. Comment and commenda- 
tion are unnecessary, as no one at the present day 
thinks of purchasing any other Medical Dictionary 
than this. — St. Lo%iis Med. and Surg. Journ., Jaa. 
1858. 

It is the foundation stone of a good medical libra- 
ry, and should always be included in the first list ©•/ 
books purchased by the medical student. — Am. Med. 
Monthly, Jan. 1858. 

A very perfect work of the kind, undoubtedly tea 
most perfect in the English language. — Med. amd 
Su7g. Reporter, Jan. 1858. 

It is now emphatically the Medical Dictionary of 
the English language, and for it there is no substi- 
tute.— N. H. Med. Journ., Jan. 1858. 

It is scarcely necessary to remark that any medi- 
cal library wanting a copy of Dunglison's Lexieoa 
must be imperfect. — Cin. Lancet, Jan. 1858. 

We have ever considered it ihebestauthority pub- 
lished, and the present edition we may safely say has 
no equal in the world. — Peninsular Med. Journal^ 
Jan. 1858. 

The most complete authority on the subject to ba 
found in any language. — Va. Med. Jo-amal, Feb. '5S, 



BY THE SAME AUTHOJt. 



THE PRACTICE OF MEDICINE. A Treatise on Special Pathology and Th& 
rapeutics. Third Edition. In two large octavo Volumes, leathe?, of 1>59Q page3. 38 25. 



AND SCIENTIFIC PUBLICATIONS. 



DUNGLISON (ROBLEY), M.D., 

Professor of Institutes of Medicine in the Jenerson Medical College, Philadelphia. 

HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and exten- 
sively modified and' enlarged, with five hundred and thirty-two illustrations. In two large and 
handsomely printed octavo volumes, extra cloth, of about 1500 pages. §7 00. 

In revising this work for its eighth appearance, the author has spared no labor to render it worthy 
a continuance of the very great favor which has been extended to it by the profession. The whole 
contents have been rearranged, and to a great extent remodelled ; the investigations which of late 
years have been so numerous and so important, have been carefully examined and incorporated, 
and the work in every respect has been brought up to a level with the present state of the subject. 
The object of the author has been to render it a concise but comprehensive treatise, containing the 
whole body of physiological science, to which the student and man of science can at all times refer 
with the certainty of finding whatever they are in search of, fully presented in all its aspects; and 
on no former edition has the author bestowed more labor to secure this result. 

We believe that it can truly be said, no more com- | The best work of the kind in the English lan- 
plete repertory of facts upon the subject treated, : guage. — Silliman's Journal. 

can anywhere befound. The author has, moreover, j The present edition the author has made a perfect 
that enviable tact at description and that facility m j rror ()f the science as it is at the present hour, 
and ease of expression which render him peculiarly | As a work upon physiology proper, the science of 



acceptable to the casual, or the studious reader. 
This faculty, so requisite in setting forth many 
graver and less attractive subjects, lends additional 
charms to one always fascinating. — Boston Med. 
tsmd Surg. Journal. 

The most complete and satisfactory system ot 
Physiology in the English language. — Amer. Med. 
Journal . 



the functions performed by the body, the student will 
find it all he wishes. — Nashville Journ. of Med. 
That he has succeeded, most admirably succeeded 
in his purpose, is apparent from the appearanee of 
an eighth edition. It is now the srreat encyclopaedia 
on the subject, and worthy of a place in every phy- 
sician's library. — Western Lancet. 



BY the same autkor. (A new edition.) 

Q-EMERAL THERAPEUTICS AND MATERIA MEDIC A; adapted for a 

Medical Text-book. With Indexes of Remedies and of Diseases and their Remedies. Sixth 
Edition, revised and improved. With one hundred and ninety-three illustrations. la two large 
and handsomely printed octavo vols., extra cloth, of about 1100 pages. $6 00. 

In announcing a new edition of Dr. Dunglison's The work will, we have little doubt, be bought 
General Tnerapeutics and Materia Medica, we nave and read by the majority of medical students; its 
so words of commendation to bestow upon a work size, arrangement, and reliability recommend it to 
whose merits have been heretofore so often and so all; no one, we venture to prediet, will study it 
j.«f3tly extolled. It must not be supposed, however, without profit, and there are few to whom it will 
Chat the present is a mere reprint of the previous not be in some measure useful as a work of refer- 
edition; the character of the author for laborious j enee. The young practitioner, more especially, will 
research, judicious analysis, and clearness of ex- find the copious indexes appended to this edi;ion of 
pressioa, is fully sustained by the numerous addi- | great assistance in the selection and preparation of 
tions he has made to the work, and the careful re- I suitable formula. — Charleston Med. Journ. and Rt- 
vision to which he has subjected the whole. — N. A. j view, Jan. 1856. 
Medite-Chir. Review, Jan. 1058. I 

BY TSE same AUTHOR. (A new Edition,.) 

NEW REMEDIES, WITH FORMULAE FOR THEIR PREPARATION AND 

ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo 
volume, extra cloth, of 770 pages. $3 75. 

One of the most useful of the author's works. — f The great learning of the author, and his remark - 
S&vlhem Medical and Surgical Journal. able industry in pushing his researches into every 

This elaborate and useful volume should be source whence information is derivable,have enabled 
found in every medical library, for as a book of re- ! him t0 throw together an extensive mass of facta 
terence, for physicians, it is unsurpassed by any and , statements, accompanied by full relerence to 
other work in existence, and the double index for < authorities; which last feature renders the work 
diseases and for remedies, will be found greatly to ! practically valuable to investigators who desire to 
(Wiiianee its vaiue.— New York Med. Gazette. examine the original papers.— The American Journal 

j of Pharmacy, 



ELLIS (BENJAMIN), M.D. 
THE MEDICAL FORMULARY : being a Collection of Prescriptions, derived 

from the writings and practice of many of the most eminent physicians of America and Europe. 
Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added 
an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. The 
whole accompanied with a few brief Pharmaceutic and Medical Observations. Eleventh edition , 
revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the 
Philadelphia College of Pharmacy. In one volume, 8vo. (Preparing for early publication.) 

This work has been allowed to remain for some time out of print, awaiting the appearance of 
the new U. S. Pharmacopoeia. Immediately on the publication of the latter it will be issued, an d 
those who have been desirous of procuring it may rely upon obtaining an edition thoroughly brought 
up with all that has appeared of value since the last edition was issued, and fully worthy to main- 
tain, Iks reputation of this old and favorite work. 



14 



BLANCHARD & LEA'S MEDICAL 



ERICHSEW (JOHN), 

Professor of Surgery in University College, London, &c. 

THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical 

Injuries, Diseases, and Operations. New and improved American, frpm the second enlarged 

and carefully revised London edition. Illustrated with over four hundred engravings on wood. 

In one large and handsome octavo volume, of one thousand closely printed pages, leather, 

raised bands., $5 00. 

The very distinguished favor with which this work has been received on both sides of the Atlan- 
tic has stimulated the author to render it even more worthy of the position which it has so rapidly 
attained as a standard authority. Every portion has been carefully revised, numerous additions 
have been made, and the most walchful care has been exercised to render it a complete exponent 
of the most advanced condition of surgical science. In this manner the work has been enlarged by 
about a hundred pages, while the series of engravings has been increased by more than a hundred, 
rendering it one of the most thoroughly illustrated volumes before the profession. The additions o:f 
the author having rendered unnecessary most of the notes of the former American editor, but little 
has been added in this country; some few notes and occasional illustrations have, however, been 
introduced to elucidate American modes of practice. 



It is, in our humble judgment, decidedly the best 
book of the kind in the English language. Strange 
that just such books are notoftener produced by pub- 
lic teachers of surgery in this country and Great 
Britain. Indeed, it is a matteT of great astonishment. 
but no less true than astonishing, that of the many 
works on surgery republished in this country within 
the last fifteen or twenty years as text-books for 
medical students, this is the only one that even ap- 
proximates to the fulfilment of the peculiar wants of 
youngmen justentennguponthe study of this branch 
of the profession. — Western. Tour .of Med. and Surgery. 

Its value is greatly enhanced by a very copious 
well-arranged index. We regard this as one of the 
most valuable contributions to modern surgery. To 
one entering his novitiate of practice, we regard it 
the most serviceable guide which he can consult. He 
will find a fulness of detailleadinghim throLgh every 



step of the operation, and not deserting him until ths 
final issue of the case is decided. — Sethoscope. 

Embracing, as will be perceived, the whole surgi- 
cal domain, and each division of itself almost com- 
plete and perfect, each chapter full and explicit, each 
subject faithfully exhibited, we can only express oui 
estimate of it in the aggregate. We consider it an 
excellent contribution to surgery, as probably the 
best single volume now extant on the subject, and 
with great pleasure we add it to our text-books. — 
Nashville Journal of Medicine and Surgery. 

Prof. Erichsen's work, for its size, has not been 
surpassed ; his nine hundred and eight pages, pro- 
fusely illustrated, are rich in physiological, patholo- 
gical, and operative suggestions, doctrines, details, 
and processes; and will prove a reliable resourea 
for information, both to physician and surgeon, in ths 
hour of peril.— IV. 0. Med. and Surg. Journal. 



FLINT (AUSTIN), M . D., 

Professor of the Theory and Practice of Medicine in the University of Louisville, &c. 

PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECT- 
ING THE RESPIRATORY ORGANS. In one large and handsome octavo volume, extra 
cloth, 636 pages. $3 00. 



We regard it, in point both of arrangement and of 
the marked ability of its treatment of the subjects, 
as destined to take the first rank in works of this 
class. So far as our information extends, it has at 
present no equal. To the practitioner, as well as 
the student, it will be invaluable in clearing up the 
diagnosis of doubtful cases, and in sheddmg light 
upon difficult phenomena. — Buffalo Med. Journal. 

A work of original observation of the highest merit. 
We recommend the treatise to every one who wishes 
to become a correct auscultator. Based to a very 
large extent upon cases numerically examined, il 
carries the evidence of careful study and discrimina- 
tion upon every page. It does credit to the author, 
and, through him, to the profession in this country 
It is, what we cannot call every book upon auscul- 
tation, a readable book. — Ann. Jour. Med. Sciences 

This volume belongs to a class of works which 
confer honor upon their authors and enrich the do- 
main of practical medicine. A cursory examination 
even will satisfy the scientific physician that Dr. 
Flint in this treatise has added to medical literature 



a work based upon original observation, and pos- 
sessing no ordinary merit.— iV. Y. Journal of Med. 
This is an admirable book, and because of its ex- 
traordinary clearness and entire mastery of 'he sub- 
jects discussed, has mads itself indispensable to 
those who are ambitious of a thorough knowledge 
of physical exploration. — Nashville Joum of Med. 

The arrangement of the subjects discussed is easy , 
natural, such as to present the facts in the most 
forcible light. Where the author has avoided being 
tediously minute or diffuse, he has nevertheless fully 
amplified the more important points. In this re- 
spect, indeed, his labors will take precedence, and 
be the means of inviting to this useful department a 
more general attention. — O. Med. and Surg. Joum. 

We hope these few extracts taken from Dr. Flint's 
work may convey some idea of its character and 
importance. We would, however, advise every phy- 
sician to at once place it in his library, feeling as- 
sured that it may be consulted with great benefit 
both by young and old. — Louisville Review. 



by the same author. {Now Ready.) 

A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND 

TREATMENT OF DISEASES OF THE HEART. In one neat octavo volume, of about 
500 pages, extra cloth. $2 75. 



We do not know that Dr. Flint has written any- 
thing which is not first rate ; but this, his latest con- 
tribution to medical literature, in our opinion, sur- 
passes all the others. The work is most comprehen- 
sive in its scope, and most sound in the views it enun- 
ciates. The descriptions are clear and methodical ; 
the statements are substantiated by facts, and are 
made with such simplicity and sincerity, that with- 
out them they would carry conviction. The style 
is admirably clear, direct, and free from dryness 
With Dr. Walshe's excellent treatise before us, we 
have no hesitation in saying that Dr. Flint's book is 
the best work on the heart in the English language. 
— Boston Med. and Surg. Journal. 

We have thus endeavored to present our readers 
With a fair analysis of this remarkable work. Pre- 



ferring to employ the very words of thedistinguished 
author, wherever it Was possible, we have essayed 
to condense into the briefest space a general view of 
his observations and suggestions, and to direct the 
attention of our brethren to the abounding stores of 
valuable matter here collected and arranged for their 
use and instruction. No medical library will here- 
after be considered complete without this volume ; 
and we trust it will promptly find its way into the 
hands of every Amen'can student and physician. — 
N. Am. Med. Chir. Review. 

With more than pleasure do we hail the advent o/ 
this work, for it fills a wide gap on the list t;f text- 
books for our schools, and is, for the practitioner, 
the most valuable practical work of its kind.— JY. O. 
Med. News. 



AND SCIENTIFIC PUBLICATIONS. 



FOWNES (GEORGE), PH. D., &c. 
A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. 

With one hundred and ninety-seven illustrations. Edited by Robert Bridges, M. D. In one 
large royal 12mo. volume, of 600 pages, extra cloth, $1 65. 

The death of the author having placed the editorial care of this work in the practised hands of 
Drs. Bence Jones and A. W. Hoffman, everything has been done in its revision which experience 
could suggest to keep it on a level with the rapid advance of chemical science. The additions 
requisite to this purpose have necessitated an enlargement of the page, notwithstanding which the 
work has been increased by about fifty pages. At the same time every care has been used to 
maintain its distinctive character as a condensed manual for the student, divested of all unnecessary 
detail or mere theoretical speculation. The additions have, of course, been mainly in the depart- 
ment of Organic Chemistry, which has made such rapid progress within the last few years, but 
yet equal attention has been bestowed on the other branches of the subject — Chemical Physics and 
Inorganic Chemistry — to present all investigations and discoveries of importance, and to keep up 
the reputation of the volume as a complete manual of the whole science, admirably adapted for the 
learner. By the use of a small but exceedingly clear type the matter of a large octavo is compressed 
within the convenient and portable limits of a moderate sized duodecimo, and at the very low price 
affixed, it is offered as one of the cheapest volumes before the profession. 

The work of Dr. Fownes has Ion? been before 
the public, and its merits have been fully appreci- 
ated as the best text-book on chemistry now in 
existence. We do not, of course, place it in a rank, 
superior to the works of Brande, Graham, Turner, 
Gregory, or Gmelin, but we say that, as a work 
for students, it is preferable to any of them.— Lon- 



Dr. Fownes' excellent work has been universally 
recognized every where in his own and this country, 
as the best elementary treatise on chemistry in the 
English tongue, and is very generally adopted, we 
believe, as the standard text- book in all i ur colleges, 
both literary and scientific— Charleston Med. J ourn. 
and Review. 

A standard manual, which has long enjoyed the 
reputation of embodying much knowledge in a small 
Bpace. The author hasachieved the difficult task of 
condensation with masterly tact. His book is con- 
cise without being dry, and brief without being too 
dogmatical or general. — Virginia Med. and Surgical 
Journal. 



don Journal of Medicine. 

A work well adapted to the wants of the student. 
It is an excellent exposition of the chief doctrines 
and facts of modern chemistry. The size of the work, 
and still more the condensed yet perspicuous style 
in which it is written, absolve it from the charges 
very properly urged against most manuals termed 
popular. — Edinburgh Journal of Medical Scienct. 



FISKE FUND PRIZE ESSAYS. — THE EF- 
FECTS OF CLIMATE ON TUBERCULOUS 
DISEASE. By Edwin Lee, 3VI. R. C. S , London, 
and THE INFLUENCE OF PREGNANCY ON 
THE DEVELOPMENT OF TUBERCLES By 



Edward Warren, M.D., of Edenton,N. C. To- 
gether in one neat 8vo. volume, extracloth. SI 00. 
FRICK ON RENAL AFFECTIONS; their Diag- 
nosis and Pathology. With illustrations. One 
volume, royal 12mo., extra cloth. 75 cents. 



FERGUSSON (WILLIAM), F. R. S., 
Professor of Surgery in King's College, London, &c. 

A SYSTEM OF PRACTICAL SURGERY. Fourth American, from the third 
and enlarged London edition. In one large and beautifully printed octavo volume, of about 700 
pages, with 393 handsome illustrations, leather. $3 00. 



GRAHAM (THOMAS), F. R. S. 
THE ELEMENTS OF INORGANIC CHEMISTRY, including the Applioa- 

tions of the Science in the Arts. New and much enlarged edition, by Henry Watts and Robert 

Bridges, M. D. Complete in one large and handsome octavo volume, of over 800 very large 

pages, with two hundred and thirty-two wood-cuts, extra cloth. $4 50. 

.£*£. Part II., completing the work from p. 431 to end, with Index, Title Matter, &c, may be 
had separate, cloth backs and paper sides. Price $2 50. 

From Prof. E. N. Horsford, Harvard College. 

It has, in its earlier and less perfect editions, been 
familiar to me, and the excellence of its plan and 
the clearness and completeness of its discussions, 
have long been my admiration.^ 

No reader of English works on this science can 



afford to be without this edition of Prof. Graham's 
Elements. — Sillimarts Journal , March, 1858. 
From Prof. Wolcott Gribbs, N. Y. Free Academy. 
The work is an admirable one in all respects, and 
its republication here cannot fail to exert a positive 
influence upon the progress of science in this country. 



GRIFFITH (ROBERT E.), M. D., &c. 
A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad- 
ministering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceu- 
tists. Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas, 
M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and 
handsome octavo volume, extra cloth, of 650 pages, double columns. $3 25. 

It was a work requiring much perseverance, and j This is a work of six hundred and fifty- one pages, 
when published was looked upon_as by far the best j embracing all on the subject of preparing and admi- 
nistering medicines that can be desired by the physi- 
| cian and pharmaceutist. — Western Lancet 

The arr.ountof useful, every-day matter. for a prac- 
ticing physician, is really immense.— Boston Med. 
<. and Surg. Journal. 

This edition has been greatly improved by the re- 
j vision and ample additions of Dr Thomas, and is 
now. we believe, one of the mosi complete works 
! of its kind in any language. The additions amount 
. to about seventy pages, and no effort has been spared 
j to include in them all the recent improvements. A 
} work of this kind appears to us indispensable 10 the 
: physician, and there is none we can more cordiallv 
' recommend— N. Y. Journal of Medicint. 



work of its kind that had issued from the American 
press. Prof. Thomas has certainly "improved," as 
well as added to this Formulary, and has rendered it 
additionally deserving of the confidence of pharma- 
ceutists and physicians. — Am. Journal of Pharmacy. 

We are happy to announce a new and improved 
edition of this, one of the most valuable and. useful 
works that have emanated from an American pen. 
It would do credit to any country, and will be found 
of daily usefulness to practitioners of medicine; it is 
better adapted to their purposes than the dispensato- 
ries. — Southern Med. and Surg. Journal. 

It is one of the most usem' books a country practi 
tuouej can possibly have.— Medical ChronicU. 



16 



BLANCHARD & LEA'S MEDICAL 



GROSS (SAMUEL DJ, M. D., 

Professor of Surgery in the Jefferson Medical College of Philadelphia, &s. 

Enlarged Edition. 

A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, and Opera- 
tive Illustrated by Twelve Hundred and Twenty-seven Engravings. Second edition 
much enlarged and carefully revised. In two large and beautifully printed octavo volumes o\ 
about twenty-two hundred pages ; strongly bound in leather. Price $12. 

The exhaustion in little more than two years of a large edition of so elaborate and comprehen- 
sive a work as this is the best evidence that the author was not mistaken in his estimate of the 
want which existed of a complete American System of Surgery, presenting the science in all its 
necessary details and in all its branches. That he has succeeded in the attempt to supplv this wani 
is shown not only by the rapid sale of the work, but also by the very favorable manner in which ii 
has been received by the organs of the profession in this country and in Europe, and by the fact that 
a translation is now preparing in Holland— a mark of appreciation not often bestowed on any scien- 
tific work so extended in size. 

The author has not been insensible to the kindness thus bestowed upon his labors, and in revising 
the work for a new edition he has spared no pains to render it worthy of the favor with which it 
has been received. Every portion has been subjected to close examination and revision ; any defi- 
ciencies apparent have been supplied, and the results of recent progress in the science and art o* 
surgery have been everywhere introduced; while the series of illustrations has been enlarged by 
the addition of nearly three hundred wood-cuts, rendering it one of the most thoroughly illustrated 
works ever laid before the profession. To accommodate these very extensive additions the work 
has been printed upon a smaller type, so that notwithstanding the very large increase in 'the matte? 
and value of the book, its size is more convenient and less cumbrous than before. Every care ha^ 
been taken m the printing to render the typographical execution unexceptionable, and it is confi- 
dently presented as a work in every way worthy of a place in even the most limited library of the 
practitioner or student. J 

Of Dr. Gross's treatise on Surgery we can say 
no more than that it is the most elaborate and com- 
plete work on this branch of the healing art which 
has ever been published in any country. A sys- 
tematic work, it admits of no analytical review; 
but, did our space permit, we should gladly give 
some extracts from it, to enable our readers to judge 
of the classical style of the author, and the exhaust- 
ing way in which each subject is treated.— Dub 
Quarterly Journal of Med. Science. 

The work is so superior to its predecessors in 
matter and extent, as well as in illustrations and 
style of publication, that we can honestly recom- 
mend it as the hest work of the kind to be takers 
home by the young practitioner.— Am. Med. Jov,rn. 

With pleasure we record the completion of this 
long-anticipated work. The reputation which the 
author has for many years sustained, both as a sur- 
geon and as a writer, had prepared us to expect a 
treatise of great excellence and originality; but we 
eonfess we were by no means prepared for the work 
which is before us — the most complete treatise upon 
surgery ever published, either in this or any other 
country, and we might, perhaps, safely say, the 
most original. There is no subject belonging pro- 
perly to surgery which has not received from the 
authoT a due share of attention. Dr. Gro?s has sup- 
plied a want in surgical literature which has long 
been felt by practitioners ; he has furnished us with 
a complete practical treatise upon surgery in all its 
departments. As Americans, we are proud of the 
achievement; as surgeons, we are most sincerely 
thankful to him for his extraordnary labors in on? 
behalf. — N. Y. Review and Buffalo Med. Journal, 



Has Dr. Gross satisfactorily fulfilled this object? 
A careful perusal of his volumes enables us to give 
an answer in the affirma tive. Not only has he given 
to the reader an elaborate and well- written account 
of his o ivn vast experience, but he has not failed to 
embody in his pages the opinions and practice of 
surgeons in this and other countries of Europe. The 
result has been a work of such completeness, that it 
has no superior in the systematic treatises on sur- 
gery which have emanated from English or Conti- 
nental authors. It has been justly objected that 
these have been far from complete in many essential 
particulars, many of them having been deficient in 
some of the most important points which should 
characterize such works Some of them have been 
elaborate — too elaborate— with respect to certain 
diseases, while they have merely glanced at, or 
given an unsatisfactory account of, others equally 
important to the surgeon. Dr. Gross has avoided 
this error, and has produced the most complete work 
that has yet issued from the press on the science and 
practice of surgery. It is not, strictly speaking, a 
Dictionary of Surgery, but it gives to the reader all 
the information that he may require for his treatment 
of surgical diseases. Having said so much, it might 
appear superfluous to add another word; but it is 
only due to Dr. Gross to state that he has embraced 
the opportunity of transferring to his pages avast 
number of engravings from English and other au- 
thors, illustrative of the pathology and treatment of 
surgical diseases. To these are added several hun- 
dred original wood-cuts. The work altogether com- 
mends itself to the attention of British surgeons, 
from whom it cannot fail to meet with extensive 
patronage. — London Lancet, Sept. 1, 1860. 

BY THE SAME AUTHOR.. 

ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, thoroughly 

revised and greatly improved. In one large and very handsome octavo volume, with about three 

hundred and fifty beautiful illustrations, of which a large number are from original drawings, 

extra cloth. $4 75. 

The very rapid advances in the Science of Pathological Anatomy during the last few years have 
rendered essential a thorough modification of this work, with a view of making it a correct expo- 
nent of the present state of the subject. The very careful manner in which this task has been 
executed, and the amount of alteration which it has undergone, have enabled the author to say that 
" with the many changes and improvements now introduced, the work may be regarded almost as 
a new treatise," while the efforts of the author have been seconded as regards the mechanical 
execution of the volume, rendering it one of the handsomest productions of the American press. 

We most sincerely congratulate the author on the We have been favorably impressed with the gene- 



successful manner in which he has accomplished his 
proposed object. His book is most admirably cal- 
culated to fill up a blank which has long been felt to 
exist in this department of medical literature, and 
as such must become very widely circulated amongst 
all classes of the profession. — Dublin Quarterly 
Journ. of Med. Science, Nov. 1857. 



manner in which Dr. Gross has executed his task 
of affording a comprehensive digest of the present 
state of the literature of Pathological Anatomy, and 
have much pleasure in recommending his work to 
our readers, as we believe one well deserving of 
diligent perusal and careful study. — Montreal Med. 
Chron., Sept. 1857. 



BY THE SAME AUTHOR. 

A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PAS- 

SAGES. In one handsome octavo volume, extra cloth, with illustrations, pp. 4S8. $2 75. 



AND SCIENTIFIC PUBLICATIONS. 



17 



GROSS (SAMUEL D.), M . D., 

Professor of Surgery in the Jefferson Medical College of Philadelphia, &c. 

A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND 

MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND, AND 
THE URETHRA. Second Edition, revised and much enlarged, with one hundred and eighty- 
four illustration?. In one large and very handsome octavo volume, of over nine hundred pages, 
extra cloth, $4 75. 



Philosophical in its design, methodical in its ar- 
rangement, ample and sound in its practical details, 
it may in truth be said to leave scarcely anything to 
be desired on so important a subject. — Boston Med. 
and Surg Journal. 

' Whoever will peruse the vast amount of valuable 
practical information it contains, will, we think. 



agree with us, that there is no work in the English 
language which can make any just pretensions to 
be its equal. — N. Y. Journal of Medicine . 

A volume replete with truths and principles of the 
utmost value in the investigation of these diseases. — 
American Medical Journal . 



GRAY (HENRY), F. R. S., 

Lecturer on Anatomy at St. George's Hospital, London, &c. 

ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. V. 

Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital ; the Dissections jointly 
by the Author and Dr. Carter. Second American, from the second revised and improved 
London edition. In one magnificent imperial octavo volume, of over 800 pages, with 388 large 
and elaborate engravings on wood. Price in extra cloth, $6 25; leather, raised bands, $7 00. 
The speedy exhaustion of a large edition of this work is sufficient evidence that its plan and exe- 
cution have been found to present superior practical advantages in facilitating the study of Anato- 
my. In presenting it to the profession a second time, the author has availed himself of the oppor- 
tunity to supply any deficiencies which experience in its use had shown to exist, and to correct 
any errors of detail, to which the first edition of a scientific work on so extensive and complicated 
a science is liable. These improvements have resulted in some increase in the size of the volume, 
while twenty-six new wood-cuts have been added to the beautiful series of illustrations which 
form so distinctive a feature of the work. The American edition has been passed through the press 
under the supervision of a competent professional man, who has taken every care to render it in 
all respects accurate, and it is now presented, without any increase of price, as fitted to maintain 
and extend the popularity which it has everywhere acquired. 



With little trouble, the busy practitioner whose 
knowledge of anatomy may have become obscured by 
want of practice, may now resuscitate his former 
anatomical lore, and be ready for any emergency. 
It is to this class of individuals, and not to the stu- 
dent alone, that this work will ultimately tend to 
be of most incalculable advantage, and we feel sat- 
isfied that the library of the medical man will soon 
be considered incomplete in which a copy of this 
work does not exist.— Madras Quarterly Journal 
of Med. Science, July, 1861. 

This edition is much improved and enlarged, and 
contains several new illustrations by Dr. Westma- 
cott. The volume is a complete companion to the 
dissecting-room, and saves the necessity of the stu- 
dent possessing a variety of " Manuals." — The Lon- 
don Lancet, Feb. 9, 1861. 

The work before us is one entitled to the highest 
praise, nnd we accordingly welcome it as a valu- 
able addition to medical literature. Intermediate 
in fulness of detail between the treatises of S.iar 
pey and of Wilson, its characteristic merit lies in 
the number and excellence of the engravings it 
contains. Most of these are original, of much 
larger than ordinary size, and admirably executed. 
The various parts are also lettered after the plan 
adopted in Holden's Osteology. It would be diffi- 
cult to over-estimate the advantages offered by this 
mode of pictorial illustration. Bones, ligaments, 
muscles, bloodvessels, and nerves are each in turn 
figured, and marked with their appropriate names ; 
thus enabling the student to comprehend, at a glance, 
what would otherwise often be ignored, or at any 
rate, acquired only by prolonged and irksome ap- 
plication. In conclusion, we heartily commend the 
work of Mr. Gray to the attention of the medical 
profession, feeling certain that it should be regarded 
as one of the most valuable contributions ever made 
to educational literature. — N. Y. Monthly Review. 
Dec. 1859. 

In this view, we regard the work of Mr. Grav as 
far better adapted to the wants of the profession, 
and especially of the student, than any treatise on 
anatomy yet published in this country. 1 1 is destined, 
we believe, to supersede ill others, both as a manual 
of dissections, and a standard of reference to the 
student of general or relative anatomy. — N. Y. 
Journal of Medicine, Nov. 1659. 

For this truly admirable work the profession is 
indebted to the distinguished author of " Gray on 
the Spleen." The vacancy it fills has been long felt 



to exist in this country. Mr. Gray writes through- 
out with both branches of his subject in view. His 
description of each particular part is followed by a 
notice of its relations to the parts with which it is 
connected, and this, too, sufficiently ample for all 
the purposes of the operative surgeon. After de- 
scribing the bones and muscles, he gives a concise 
statement of the fractures to which the bones of 
the extremities are most liable, together with the 
amount and direction of the displacement to which 
the fragments are subjected by muscular action. 
The section on arteries is remarkably full and ac- 
curate. Not only is the surgical anatomv given to 
every important vessel, with directions for its liga- 
tion, but at the end of the .description of each arte- 
rial trunk we have a useful summary of the irregu- 
larities which may occur in its origin, course, and 
termination. — N. A. Med. Chir. Review, Mar. 1859. 

Mr. Gray's book, in excellency of arrangement 
and completeness of execution, exceeds any work 
on anatomy hitherto published in the English lan- 
guage, affording a complete view of the structure of 
the human body, with especial reference to practical 
surgery. Thusthe volume constitutes a perfectbook 
of reference for the practitioner, demanding a place 
in even the most limited library of the physician or 
surgeon, and a work of necessity for the student to 
fix in his mind what he has learned by the dissecting 
knife from the book of nature. — The Dublin Quar- 
terly Journal of Med. Sciences, Nov. 1858. 

In our judgment, the mode of illustration adopted 
in the present volume cannot but present many ad 
vantages to the student of anatomy. To the zealous 
disciple of Vesalius, earnestly desirous of real im- 
provement, the book will certainly be of immense 
value p but, at the same time, we must also confess 
that to those simply desirous of "cramming" it 
will be an undoubted godsend. The peculiar value 
of Mr. Gray's mode of illustration is nowhere more 
markedly evident than in the chapter on osteology, 
and especially in those portions which treat of the 
bones of the head and of their development. The 
study of these parts is thus made one of comparative 
ease, if not of positive pleasure: and those bugbears 
of the student, the temporal ana sphenoid bones, are 
shorn of half their terrors. It is, in our estimation, 
an admirable and complete text-book for the student, 
and a useful work of reference for the practitioner; 
its pictorial character forming a novel element, to 
which we have already sufficiently alluded. — Am. 
Journ. Med. Sci., July, 1859. 



J.S 



BLANCHARD & LEA'S MEDICAL 



GIBSON'S INSTITUTES AND PRACTICE OF 

SURGERY. Eighth edition, improved and al- 
tered. With thirty-four plates. In two handsome 
octavo volumes, containing about 1,000 pages, 
leather, raised band 1 !. $6 50. 

GARDNER'S MEDICAL CHEMISTRY, for the 
use of Students and the Profession. In one royal 
12mo. vol., cloth, pp. 396, with wood-cuts. SI. 

GLUGE'S ATLAS OF PATHOLOGICAL HIS- 
TOLOGY. Translated, with Notes and Addi- 



tions, by Joseph Leidt, M. D. In one volume, 
very large imperial quarto, extra cloth, with 320 
copper- plate figures, plain and colored, S5 00. 

HUGHES' INTRODUCTION TO THE PRAC- 
TICE OF AUSCULTATION AND OTHER 
MODES OF PHYSICAL DIAGNOSIS. IN DIS- 
EASES OF THE LUNGS AND HEART. Se- 
cond edition 1 vol. royal 12mo., ex. cloth, pp. 
304. SI 00. 



HAMILTON (FRANK H.), M. D., 

Professor of Surgery in the Long Island College Hospital. 

A PRACTICAL TREATISE ON FRACTURES AND DISLOCATIONS. 

Second edition, revised and improved. In one large and handsome octavo volume, of over 750 
pages, with nearly 300 illustrations, extra cloth, $4 75. (Just Ready, May, 1863.) 

The early demand for a new edition of this work shows that it has been, successful in securing 
the confidence of the profession as a standard authority for consultation and reference on its import- 
ant and difficult subject. In again passing it through the press, the author has taken the opportu- 
nity to revise it carefully, and introduce whatever improvements have been suggested by further 
experience and observation. An additional chapter on Gun-shot Fractures will be found to adapt 
it still more fully to the exigencies of the time. 



Among the many good workers at surgery of whom 
America may now boast rot the least is Frank Hast- 
ings Hamilton ; and the volume before us i s (we say 
it with a pang of wounded patriotism) the best and 
handiest book on the subject in the Er.glish lan- 
guage. It is in vain to attempt a review of it; 
nearly as vain to seek for any sins, either of com- 
mission or omission. We have seen no work on 
practical surgery which we would sooner recom- 
mend to our brother surgeons, especially those of 
" the services," or those whose practice lies in dis- 
tricts where a man has necessarily to rely on his 
own unaided resources. The practitioner will find 
in it directions for nearly every possible accident, 
easily found and comprehended ; and much pleasant 
reading for him to muse over in the after considera- 
tion of his cases. — Edinburgh Med. Journ. Feb. 1861. 

This is a valuable contribution to the surgery of 
most important affections, and is the more welcome, 
inasmuch as at the present time we do not possess 
a single complete treatise on Fractures and Dislo- 
cations in the English language. It has remained for 
our American brother to produce a complete treatise 
upon the subject, and bring together in a convenient 
form those alterations and improvements that have 
been made from time to time in the treatment of these 
affections. One great and valuable feature in the 
work before us is the fact that it comprises all the 
Improvements introduced into the practice of both 
English and American surgery, and though far from 
omitting mention of our continental neighbors, the 
author by no means encourages the notion — but too 
prevalent in some quarters— that nothing is good 
unless imported from France or Germany. The 
latter half of the work is devoted to the considera- 
tion of the various dislocations and their appropri- 
ate treatment, and its merit is fully equal to that of 
the preceding portion. — The London Lancet,M.a.y 5, 
1860. 

It is emphatically the book upon the subjects of 
which it treats, and we cannot doubt that it will 
continue so to be for an indefinite period of time. 



When we say, however, that we believe it will at 
once take its place as the best book for consultation 
by the practitioner; and that it will form the most 
complete, available, and reliable guide in emergen- 
cies of every nature connected with its subjects ; and 
also that the student of surgery may make it his text- 
book with entire confidence, and with pleasure also, 
from its agreeable and easy style— we think our own 
opinion may be gathered as to its value. — Boston 
Medical and Surgical Journal, March 1, 1860. 

The work is concise, judicious, and accurate, and 
adapted to the wants of the student, practitioner, 
and investigator, honorable to the author and to the 
profession. — Chicago Med. Journal, March, 1860. 

We regard this work as an honor not only to its 
author, but to the profession of our country. Were 
we to review it thoroughly , we could not convey to 
the mind of the reader more forcibly our honest 
opinion expressed in the few words — we think it the 
best book of its kind extant. Every man interested 
in surgery will soon have this work on his desk. 
He who does not, will be the loser. — New Orleans 
Medical News, March, 1860. 

Dr. Hamilton is fortunate in having succeeded in 
filling the void, so long felt, with what cannot fail 
to be at once accepted as a model monograph in some 
respects, and a work of classical' authority. We 
sincerely congratulate the profession of the United 
States on the appearance of such a publication from 
one of their number. We have reason to be proud 
of it as an original work, both in a literary and sci- 
entific point of view, and to esteem it as a valuable 
guide in a most difficult and important branch of 
study and practice. On every account, therefore, 
we hope that it may soon be widely known abroad 
as an evidence of genuine progress on this side of 
the Atlantic, and further, that it may be still more 
widely known at home as an authoritative teacher 
from which every one may profitably learn, and as 
affording an example of honest, well-directed, and 
untiring industry in authorship which every surgeon 
may emulate.- Am. Med. Journal, April, 1860. 



HOBLYN (RICHARD D.), M. D. 
A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE 

COLLATERAL SCIENCES. A new American edition. Revised, with numerous Additions, 
by Isaac Hays, M. D., editor of the" American Journal of the Medical Sciences." In one large 
royal 12mo. volume, leather, of over 500 double columned pages. $1 50. 

To both practitioner and student, we recommend use ; embracing every department of medical scienc* 



this dictionary as being convenient in size, accurate 
in definition, and. sufficiently full and complete for 
ordinary consultation. — Charleston Med. Journ. 

We know of no dictionary better arranged and 
adapted. Itisnotencumbered with theobsoleteterma 
of a bygone age, but it contains all that are now in 



down to the very latest date.— Western J^ancet. 

Hoblyn's Dictionary has long been a favorite with 
us. It is the best book of definitions we have, and 
ought always to be upon the student's table. — 
Southern Med. and Surg. Journal. 



HOLLAND'S MEDICAL NOTES AND RE- 
FLECTIONS. From the third London edition. 
In one handsome octavo volume, extra cloth. $3. 

HORNER'S SPECIAL ANATOMY AND HIS- 



TOLOGY. Eighth edition. Extensively revised 
and modified. In two large octavo volumes, ex- 
tra cloth, of more than 1000 pages, with over 306 
illustrations. $6 00. 



AND SCIENTIFIC PUBLICATIONS. 



19 



HODGE (HUGH L.), M. D., 

Professor of Midwifery and the Diseases of Women and Children in the University of Pennsylvania, &e. 

ON DISEASES PECULIAR TO WOMEN, including Displacements of the 
Uterus. With original illustrations. In one beautifully printed octavo volume, of nearly 500 
pages, extra cloth. $3 25. 



We will say at once that the work fulfils its object 
capitally well - } and we will moreover venture the 
assertion that it will inaugurate an improved prac- 
tice throughout this whole country. The secrets of 
the author's success are so clearly revealed that the 
attentive student cannot fail to insure a goodly por- 
tion of similar success m his own practice. It is a 
credit to all medical literature; and we add, that 
the physician who does not place it in his library, 
and who does not faithfully con its pages, will lose 
a vast deal of knowledge that would be most useful 
to himself and beneficial to his patients. It is a 
practical work of the highest order of merit; and it 
will take rank as such immediately. — Maryland and 
Virginia Medical Journal, Feb. 1661. 

This contribution towards the elucidation of the 
pathology and treatment of some of the diseases 
peculiar to women, cannot fail to meet with a favor- 
able reception from the medical profession. The 
character of the particular maladies of which the 
work before us treats; their frequency, variety, and 
abscui ity ; the amount of malaise and even of actual 
suffering by which they are invariably attended; 
their obstinacy, the difficulty with which they are 
overcome, and their disposition again and again to 
recur — these, taken in connection with the entire 
competency of the author to render a correct ac- 
count of their nature, their causes, and their appro- 



priate management — his ample experience, his ma- 
tured judgment, and his perfect conscientiousness — 
invest this publication with an interest and value to 
which few of the medical treatises of a recent date 
can lay a stronger, if, perchance, an equal claim. — 
Am. Journ. Med. Sciences, Jan. 1861. 

Indeed, although no part of the volume is not emi- 
nently deserving of perusal and study, we think that 
the nine chapters devoted to this subject, are espe- 
cially so, and we know of no more valuable mono- 
graph upon the symptoms, prognosis, and manage- 
ment of these annoying maladies than is constituted 
by this part of the work. We cannot but regard it 
as one of the most original and m jst practical works 
of the day ; one which every accoucheur and physi- 
cian should most carefully re id; for we are per- 
suaded that he will arise from its perusal with new 
ideas, which will induct him into a more rational 
practice in regard to many a suffering female, who 
may have placed her health in his hands. — British 
American Journal, Feb. 1861. 

Of the many excellences of the work we will not 
speak at length. We advise all who would acquire 
a kcowledge of the proper management of the mala- 
dies of which it treats, to study it with care. The 
second part is of itself a most valuable contribution 
to the practice of our art. — Am. Med. Monthly and 
New York Review, Feb. 1861. 



The illustrations, which are all original, are drawn to a uniform scale of one-half the natural size. 



HABERSHON (S. O.), M . D., 

Assistant Physician to and Lecturer on Materia Medica and Therapeutics at Guy's Hospital, &c. 

PATHOLOGICAL AND PRACTICAL OBSERVATIONS ON DISEASES 

OF THE ALIMENTARY CANAL, (ESOPHAGUS, STOMACH, C^CUM, AND INTES- 
TINES. With illustrations on wood. In one handsome octavo volume of 312 pages, extra 
cloth $1 75. 



JONES (T. WHARTON), F. R. S., 

Professor of Ophthalmic Medicine and Surgery in University College, London, &c. 

THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE 

AND SURGERY. With one hundred and ten illustrations. Second American from the second 
and revised London edition, with additions by Edward Hartshorne, M. D., Surgeon to Wills' 
Hospital, &c. In one large, handsome royal 12mo. volume, extra cloth, of 500 pages. $1 50. 



JONES (C. HANDHELD), F. R. S., &. EDWARD H. SIEVEKING, M.D., 

Assistant Physicians and Lecturers in St. Mary's Hospital, London. 

A MANUAL OF PATHOLOGICAL ANATOMY. First American Edition, 

Revised. With three hundred and ninety-seven handsome wood engravings. In one large and 

beautiful octavo volume of nearly 750 pages, extra cloth. $3 75. 

As a concise text-book, containing, in a condensed \ obliged to glean from a great number of monographs, 
form, a complete outline of what is known in the ! and the field was so extensive that but few cultivated 
domain of Pathological Anatomy, it is perhaps the ! it with any degree of success. As a simple work 
best work in the English language. Its great merit j of reference, therefore, it is of great value to the 
consists in its completeness and brevity, and in this ; student of pathological anatomy, and should be in 
respect it supplies a great desideratum in our lite- , every physician's library. — Western Lancet. 
rature. Heretofore the student of pathology was I 



KIRKES (WILLIAM SENHOUSE), M. D., 

Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c. 

A MANUAL OF PHYSIOLOGY. A new American, from the third and 

improved London edition. With two hundred illustrations. In one large and handsome royal 

12mo. volume, extra cloth, pp. 586. $2 00. 

This is a new and very much improved edition of l and its carefully cited authorities. It is the most 
Dr. Kirkes' well-known Handbook of Physiology, convenient of text-books. These gentlemen, Messrs. 
It combines conciseness with completeness, and is, j Kirkes and Paget, have the gift of telling us what 
therefore, admirably adapted for consultation by the j we want to know, without thinking it necessary 



busy practitioner. — Dublin Quarterly Journal 

One of the very best handbooks of Physiology we 
possess— presenting just such an outline of the sci- 
ence as the student requires during his attendance 
upon a course of lectures, ot for reference whilst 
preparing for examination.— Am. Medical Journal, 
lis excellence is in its compactness, its clearness, 



to tell us all they know. — Boston Med. and Surg. 
Journal. 

For the student beginning this study, and the 
practitioner who has but leisure to refresh his 
memory, this book is invaluable, as it contains all 
that it is important to know. — Charleston Mid. 
Journal. 



20 



BLANCHARD & LEA'S MEDICAL 




KNAPP'S TECHNOLOGY ; or, Chemistry applied 
to the Arts and to Manufactures. Edited by Dr. 
Ronalds, Dr. Richardson, and Prof. W. R. 
Johnson. In twohandsonu 8vo. vols, extra cloth, 
with about 500 wood- engravings. $6 00. 



LAYCOCK'S LECTURES ON THE PRINCf- 
PLES AND METHODS OF MEDICAL OB- 
SERVATION AND RESEARCH. For the Use 
of Advanced Students and Junior Practitioners. 
In one royal 12mo. volume, extra cloth. Price $1. 



LALLEMAND AND WILSON. 
l PRACTICAL TEEATISB ON THE CAUSES, SYMPTOMS, AND 

TREATMENT OF SPERMATORRHOEA. By M. Lallemand. Translated and edited by 

Henry J McDougall. Third American edition. To which is added ON DISEASES 

OF THE VESICUL^E SEMINALES; and their associated organs. With special refer- 
ence to the Morbid Secretions of the Prostatic and Urethral Mucous Membrane. By Marris 
Wilson, M. D. In one neat octavo volume, of about 400 pp., extra cloth. $2 00. 



LA ROCHE (R.), M. D., &c. 
YELLOW FEVER, considered in its Historical, Pathological, Etiological, and 

Therapeutical Relations. Including a Sketch of the Disease as it has occurred in Philadelphia 
from 1699 to 1854, with an examination of the connections between it and the fevers known under 
the same name in other parts of temperate as well as in tropical regions. In two large and 
handsome octavo volumes of nearly 1500 pages, extra cloth. $7 00. 



From Professor S. H. Dickson, Charleston, S. C, 
September 18, 1855. 

A monument of intelligent and well applied re- 
search, almost v/ithout example. It is, indeed, in 
itself, a large library, and is destined to constitute 
the special resort as a book of reference, in the 
subject of which it treats, to all future time. 

We have not time at present, engaged as we are, 
by day and by night, in the work of combating this 
very disease, now prevailing in our city, to do more 
than give this cursory notice of what we consider 
as undoubtedly the most able and erudite medical 
publication our country has yet produced. But in 
view of the startling fact, that this, the most malig- 



nant and unmanageable disease of modern times, 
has for several years been prevailing in our country 
to a greater extent than ever before; that it is no 
longer confined to either large or small cities, but 
penetrates country villages, plantations, and farm- 
houses; that it is treated with scarcely better suc- 
cess now than thirty or forty years ago ; that there 
is vast mischief done by ignorant pretenders to know- 
ledge in regard to the disease, and in view of the pro- 
bability that a majority of southern physicians will 
be call ed upon to treat the disease, we trust that this 
able and comprehensive treatise will be very gene- 
rally read m the south. — Memphis Med. Recorder. 



BY THE SAME AUTHOR. 

PNEUMONIA ; its Supposed Connection, Pathological and Etiological, with Au- 
tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one 
handsome octavo volume, extra cloth, of 500 pages. $3 00. 



LAWRENCE (W.), F. R. S., &c. 
A TREATISE ON DISEASES OF THE EYE. A new edition, edited, 

with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Will's Hospi- 
tal, &c. In one very large and handsome octavo volume, of 950 pages, strongly bound in leather 
with raised bands. $6 00. 

LUDLOW (J. L.), M. D. 
A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, 

Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To 
which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended 
and enlarged. With 370 illustrations. In one handsome royal 12mo. volume, leather, of 81(5 
large pages, $2 50. 
We know of no better companion for the student j crammed into his head by the various professors to 

during the hours spent in the lecture room, or to re- whom he is compelled to listen. — Western Lancet, 

fresh, at a glance, his memory of the various topics | May, 1857. 



LEHMANN (C. G.) 
PHYSIOLOGICAL CHEMISTRY. Translated from the second edition by 
George E. Day, M. D., F. R. S., &c, edited by R. E. Rogers, M. D., Professor of Chemistry 
in the Medical Department of the University of Pennsylvania, with illustrations selected from 
Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Complete in two large 
and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus- 
trations.' $6 00. 



The work of Lehmann stands unrivalled as the 
most comprehensive book of reference and informa- 
tion extant on every branch of the subject on which 
it treats. — Edinburgh Journal of Medical Science. 



The most important contribution as yet made to 
Physiological Chemistry — Am. Journal Med. Sci- 
ences, Jan. 1856. 



BY THE SAME AUTHOR. 

MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, 

with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital 
Force, by Professor Samuel Jackson, M. D., of the University of Pennsylvania. With illus- 
trations on wood. In one very handsome octavo volume, extra cloth, of 336 pages. $2 25. 

From Prof. Jacksoyi's Introductory Essay. 
In adopting the handbook of Dr. Lehmann as a manual of Organic Chemistry for the use of the 
students of the University, and in recommending his original work of Physiological Chemistry 
for their more mature studies, the high value of his researches, and the great weight of his autho- 
rity in that important department of medical science are fully recognised. 



AND SCIENTIFIC PUBLICATIONS, 



21 



LYONS (ROBERT D.), K. C. C, 

Late Pathologist in-chief to the British Army in the Crimea, &c. 

A TREATISE ON FEVER; or, selections from a course of Lectures on Fever. 

Being- part of a course of Theory and Practice of Medicine. Iu one neat octavo volume, of 362 

pages, extra cloth; $2 00. {Just Issued .) 

We have great pleasure in recommending Dr.] cine. We consider the work a most valuable addi- 
Lyons' work on Fever to the atteniion of the pro- 



fession. It is a work which 

the author's previous well-earned reputation, as a 
diligent, careful, and accurate observer.— British 
Med. Journal, March 2, 1861. 

Taken as a whole we can recommend it in the 
highest terms as well worthy the careful perusal 
and study of every student and practitioner of medi- 



tion to medical literature, and one destined to wield 
t fail to enhance j no little influence over the mind of the profession. — 
Med. and Surg. Reporter, May 4, 1S61. 

This is an admirable work upon the most remark- 
able and most important class of diseases to which 
mankind are liable. — Med. Journ. of N. Carolina, 
May, 1861. 



MEIGS (CHARLES D.), M. D., 

Lately Professor of Obstetrics, &c. in the Jefferson Medical College, Philadelphia. 

OBSTETRICS : THE SCIENCE AND THE ART. Fourth edition, revised 

and improved. With one hundred and twenty-nine illustrations. In one beautifully printed octavo 

volume, leather, of seven hundred and thirty large pages. $4 00. (Now Ready, Feb. 1863.) 
From the Author's Preface. 

" [n this edition I have endeavored to amend the work by changes in its form ; by careful cor- 
rections of many expressions, and by a few omissions and some additions as to the text. 

"The Student will find that I have recast the article on Placenta Prsevia, which I was led to do 
out of my desire to notice certain new modes of treatment which I regarded as not only ill founded 
as to the'philosophy of our department, but dangerous to the people. 

" In changing the form of my work by dividing it into paragraphs or sections, numbered from 1 
to 959, I thought to present to the reader a common-place book of the whole volume. Such a table 
of contents ought to prove both convenient and useful to a Student while attending public lectures." 

A work which has enjoyed so extensive a reputation and has been received with such general 
favor, requires only the assurance that the author has labored assiduously to embody in his new 
edition whatever has been found necessary to render it fully on a level with the most advanced 
state of the subject. Both as a text-book for the student and as a reliable work of reference for 
the practitioner, it is therefore to be hoped that the volume will be found worthy a continuance of 
the confidence reposed in previous editions. 

As an elementary treatise — concise, but, ■withal, I acquisition to obstetric literature, and one that will 
clear and comprehensive — we know of no one better [ very much assist the practitioner under many circum- 
adapted for the use of the student ; while the young stances of doubt and perplexity. — The Dublin Quar- 
practitioner will find in it a body of sound doctrine, | terly Journal. 
and a series of excellent practical directions, adapted 



to all the conditions of the various forms of labor and 
their results, which he will be induced, we are per- 
suaded, again and again to consult, and always with 
profit. It has seldom been our lot to peruse a work 
upon the subject, from which we have received great- 
er satisfaction, and which we believe to be better cal- 
culated to communicate to the student correct and 
definite views upon the several topics embraced with- 
in the scope of its teachings. — Am. Journ. Med. Sei. 
An author of established merit, a professor of Mid- 
wifery, and a practitioner of high reputation and im- 
mense experience — we may assuredly regard his work 



These various heads are subdivided so well, so lu- 
cidly explained, that a good memory is all that is 
necessary in order to put the reader in possession of 
a thorough knowledge of this important subject. Dr. 
Meigs has conferred a great benefit on the profession 
in publishing this excellent work. — St. Louis Medical 
and Surgical Journal. 

He has an earnest way with him, when speaking of 
the most elementary subjects, which fixes the atten- 
tion and adds much value to the work as a text-book 
for students ; indeed it is obviously the result of much 
practical acquaintance with the art of teaching. — The 



now before us as representing the most advanced state j British and Foreign Med.-Cliirurg. Review. 

of obstetric science in America up to the time at which We are acquainted with no work on midwifery of 

he writes. "We consider Dr. Meigs' book as a valuable I greater practical value. — Boston Med. & Surg. Journ. 

BY the same author. (Jtist Issued .) 

WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Leo- 

tures to his Class. Fourth and Improved edition. In one large and beautifully printed octava 
volume, extra cloth, of over 700 pages. $3 60. 

which cannot fail to recommend the volume to the 



In other respects, in our estimation, too much can- 
not be said in praise of this work. It abounds with 
beautiful passages, and for conciseness, for origin- 
ality, and for all that is commendable in a work on 
the diseases of females, it is not excelled, and pro- 
bably not equalled in the English language. On the 
whole, we know of no wont on the diseases of wo- 
men which we can so cordially commend to the 
student and practitioner as the one before us. — Ohio 
Med. and Surg. Journal. 

The body of the book is worthy of attentive con- 
sideration, and is evidently the production of a 
clever, thoughtful, and sagacious physician. Dr. 
Meigs's letters on the diseases of the external or- 
gans, contain many interesting and rare cases, and 
many instructive observations. We take our leave 
of Dr. Meigs, with a high opinion of his talents and 
originality.— The British and Foreign Medico-Chi- 
rurgical Review. 

Every chapter is replete with practical instruc- 
tion, and bears the impress of being the composition 
of an acute and experienced mind. There is a terse- 
ness, and at the same time an accuracy in his de- 
scription oi symptoms, and in the rules for diagnosis, 



attention of the reader. — Ranking'' s Abstract. 

It contains a vast amount of practical knowledge, 
by one who has accurately observed and retained 
the experience of many years. — Dublin Quarterly 
Journal. 

Full of important matter, conveyed in a ready and 
agreeable manner. — St. Louis Med. and Surg. Jour. 

There is an off-hand fervor, a glow, and a warm- 
heartedness infecting the effort of Dr. Meigs, which 
is entirely captivating, and which absolutely hur- 
ries the reader through from beginning to end. Be- 
sides, the book teems with solid instruction, and 
it shows the very highest evidence of ability, viz., 
the clearness with which the information is pre- 
sented. We know of no better test of one's under- 
standing a subject than the evidence of the power 
of lucidly explaining it. The most elementary, as 
well as the obscurest subjects, under the pencil of 
Prof. Meigs, are isolated and made to stand out in 
such bold relief, as to produce distinct impressions 
upon the mind and memory of the reader. — Thi 
Charleston Med. Journal. 



22 



BLANCHARD & LEA'S MEDICAL 



MEIGS (CHARLES D.LM. D., 

Lately Professor of Obstetrics, &c, in Jefferson Medical College, Philadelphia. 

ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED 

FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome 
octavo volume, extra cloth, of 365 pages. $2 50. 



The instructive and interesting author of this 
work, whose previous labors have placed his coun- 
trymen under deep and abiding obligations, again 
challenges their admiration in the fresh and vigor- 
ous, attractive and racy pages before us. It is a de- 

BV THE SAME AUTHOR 

A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK 

OF THE UTERUS. With numerous plates, drawn and colored from nature in the highest 
style of art. In one handsome octavo volume, extra cloth. $4 50. 



lectable book. * * * This treatise upon child- 
bed fevers will have an extensive sale, being des- 
tined, as it deserves, to find a place in the Library 
of every practitioner who scorns to lag in the rear. — 
Nashville Journal of Medicine and Surgery. 



WITH COLORED PLATES. 



MACL1SE (JOSEPH), SURGEON. 
SURGICAL ANATOMY. Forming one volume, very large imperial quarto, 

With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Con- 
taining one hundred and ninety Figures, many of them the size of life. Together with copious 
and explanatory letter-press. Strongly and handsomely bound in extra cloth, being one of the 
cheapest and best executed Surgical works as yet issued in this country. $11 00. 

Gentlemen preparing for service in the field or hospital will find these plates 
of the highest practical value, either for consultation in emergencies or to refresh 
their recollection of the dissecting room. 

*„* The size of this work prevents its transmission through the post-office as a whole, but those 
who desire to have copies forwarded by mail, can receive them in five parts, done up in stout 
wrappers. Price $9 00. 

A work which has no parallel in point of accu- 
racy and cheapness in the English language. — N. Y. 
Journal of Medicine. 

We are extremely gratified to announce to the 
profession the completion of this truly magnificent 
work, which, as a whole, certainly stands unri- 
valled, both for accuracy of drawing, beauty of 
coloring, and all the requisite explanations of the 
subject in hand. — The New Orleans Medical and 
Surgical Journal. 

This is by far the ablest work on Surgical Ana- 
tomy that has come under our observation. W« 
know of no other work that would justify a stu- 
dent, in any degree, for neglect of actual dissec- 
tion. In those sudden emergencies that so often 
arise, and which require the instantaneous command 
of minute anatomical knowledge, a work of this kind 
keeps the details of the dissecting-room perpetually 
fresh in the memory. — The Western Journal of Medi- 
cine and Surgery. 



One of the greatest artistic triumphs of the age 
in Surgical Anatomy. — British American Medical 
Journal . 

No practitioner whose means will admit should 
fail to possess it. — Banking's Abstract. 

Too much cannot be said in its praise; indeed, 
we have not language to do it justice. — Ohio Medi- 
cal and Surgical Journal. 

The most accurately engraved and beautifully 
colored plates we have ever seen in an American 
book — one of the best and cheapest surgical works 
ever published. — Buffalo Medical Journal. 

It is very rare that so elegantly printed, so well 
illustrated, and so useful a work, is offered at so 
moderate a price. — Charleston Medical Journal. 

Its plates can boast a superiority which places 
them almost beyond the reach of competition. — Medi- 
tal Examiner. 

Country practitioners will find these plates of im- 
mense value.— N. Y. Medical Gazette. 



MILLER (HENRY), M. D., 

Professor of Obstetrics and Diseases of Women and Children in the University of Louisville. 

PRINCIPLES AND PRACTICE OF OBSTETRICS, &o. ; including the Treat- 
ment of Chronic Inflammation of the Cervix and Body of the Uterus considered as a frequent 
cause of Abortion. With about one hundred illustrations on wood. In one very handsome oc- 
tavo volume, of over 600 pages, extra cloth. $3 75. 

tion to which its merits justly entitle it. — The Cin- 



We congratulate the author that the task is done. 
We congratulate him that he has given to the medi- 
cal public a work which will secure for him a high 
and permanent position among the standard autho- 
rities on the principles and practice of obstetrics. 
Congratulations are not less due to the medical pro- 
fession of this country, on the acquisition of a trea- 
tise embodying the results of the studies, reflections, 
and experience of Prof. Miller .-^-Buffalo Medical 
Journal. 

In fact, this volume must take its place among the 
standard systematic treatises on obstetrics ; a posi- 



cinnati Lancet and Observer. 

A most respectable and valuable addition to our 
home medical literature, and one reflecting credit 
alike on the author and the institution to which he 
is attached. The student will find in this work a 
most useful guide to his studies; the country prac- 
titioner, rusty in his reading, can obtain from its 
pages a fair resume of the modern literature of the 
science ; and we hope to see this American produc- 
tion generally consulted by the profession. — Va. 
Med. Journal. 



MACKENZIE (W.), M.D., 

Surgeon Oculist in Scotland in ordinary to Her Majesty, &c. &c. 

A PRACTICAL TREATISE ON DISEASES AND INJURIES OF THE 

EYE. To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section of 
the Human Eyeball, by Thomas Wharton Jones, F. R. S. From the Fourth Revised and En- 
larged London Edition. With Notes and Additions by Addinell Hewson, M. D., Surgeon to 
Wills Hospital, &c. &c. In one very large and handsome octavo volume, extra cloth, with plates 
and numerous wood-cuts. $5 25. 



The treatise of Dr. Mackenzie indisputably holds 
the first place, and forms, in respect of learning and 
research, an Encyclopaedia unequalled in extent by 
any other work of the kind , ei ther English or foreign . 
— Dixon on Diseases of the Eye. 



We consider it the duty of every one who has the 
love of his profession and the welfare of his patient 
at heart, to make himself familiar with this the most 
complete work in the English language upon the dis- 
eases of the eye. — Med. Times and Gazette. 



AND SCIENTIFIC PUBLICATIONS 



23 



MILLER (JAMES), F. R. S. E., 

Professor of Surgery in the University of Edinburgh, ice. 

PRINCIPLES OF SURGERY. Fourth American, from the third and revised 

Edinburgh edition. In one large and very beautiful volume, extra cloth, of 700 pages, with 
two hundred and forty illustrations on wood. $3 75. 



BY THE SAME AUTHOR. 



THE PRACTICE OF SURGERY. Fourth American from the last Edin- 

burgh edition. Revised by the American editor. Illustrated by three hundred and sixtv-four 
engravings on wood. In one large octavo volume; extra cloth, of nearly 700 pages. $3 75. 



No encomium of ours could add to the popularity 
of Miller's Surgery. Its reputation in this country 
is unsurpassed by that of any other work, and, when 
taken in connection with the author's Principles of 
Surgery, constitutes a whole, without reference to 
which no conscientious surgeon would be willing to 
practice his art.— Southern Med. and Surg. Journal. 

It is seldom that two volumes have ever made so 
profound an impression in so short a time as the 
"Principles" and the "Practice" of Surgery by 
Mr. Miller — or so richly merited the reputation they 
have acquired. The author is an eminently sensi- 
ble, practical, and well-informed man, who knows 
exactly what he is talking about and exactly how to 
talk it. — Kentucky Medical Recorder. 

By the almost unanimous voice of the profession, 



his works, both on the principles and practice of 
surgery have been assigned the highest rank. If we 
were limited to but one work on surgery, that one 
should be Miller's, as we regard it as superior to all 
others. — St. Louis Med. and Surg. Journal. 

The author has in this and his " Principles," pre- 
sented to the profession one of the most complete and 
reliable systems of Surgery extant. His style of 
writing is original, impressive, and engaging, ener- 
getic, concise, and lucid. Few have the faculty of 
condensing so much in small space, and at the same 
time so persistently holding theattention. Whether 
as a text-book for students or a book of reference 
for practitioners, it cannot be too strongly recom- 
mended. — Southern Journal of Med. and Physical 
Sciences. 



MORLAND (W. W.), M. D., 

Fellow of the Massachusetts Medical Society, &c. 

DISEASES OF THE URINARY ORGANS; a Compendium of their Diagnosis, 

Pathology, and Treatment. With illustrations. In one large and handsome octavo volume, oi 

about 600 pages, extra cloth. 

refer. This desideratum has been supplied by Dr. 
Morland, and it has been ably done. He has placed 
before us a full, judicious, and reliable digest. 
Each subject is treated with sufficient minuteness, 
yet in a succinct, narrational style, such as to render 
the worif one of great interest, and one which will 
prove in the highest degree useful to the general 
practitioner. — N. Y. Joum. of Medicine, 



50. 

Taken as a whole, we can recommend Dr. Mor- 
land's compendium as a very desirable addition to 
the library of every medical or surgical practi- 
tioner.— B rit.and For. Med.-C hir. Rev., April, 1859. 

Every medical practitioner whose attention has 
been to any extent attracted towards the class of 
diseases to which this treatise relates, must have 
often and sorely experienced the want of some full, 
yet concise rscent compendium to which he could 



BY THE SAME AUTHOR. 



THE MORBID EFFECTS OF THE RETENTION IN THE BLOOD OF 

THE ELEMENTS OF THE URINARY SECRETION. Being the Dissertation to which the 
Fiske Fund Prize was awarded, July 11, 1861. In one small octavo volume, 83 pages, extra 
cloth. 75 cents. 



MONTGOMERY (W. F.), M. D., M. R. I. A., &.C., 

Professor of Midwifery in the King and Queen's College of Physicians in Irehind, &c. 

AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREGNANCY. 

With some other Papers on Subjects connected with Midwifery. From the second and enlarged 
English edition. With two exquisite colored plates, and numerous wood-cuts. In one very 
handsome octavo volume, extra cloth, of nearly 600 pages. $3 75. 

fresh, and vigorous, and classical is our author's 
style; and one forgets, in the renewed charm of 
every page, that it, and every line, and every word 



A book unusually rich in practical suggestions. — 
Am. Journal Med. Sciences, Jan. 1857. 



These several subjects so interesting in them- 
selves, and so important, every one of them, to the 
most delicate and precious of social relations, con- 
trolling often the honor and domestic peace of a 



has been weighed and reweighed through years of 
preparation ; that this is of all others the book of 
Obstetric Law, on each of its several topics ; on all 



family, the legitimacy of offspring, or the life of its I P omts connected with pregnancy, to be everywhere 
parent, are all treated with an ele-ance of diction, received as a manual of special jurisprudence, at 
fulness of illustrations, acutenessand justice of rea- once announcing fact, affording argument, establish- 
soning, unparalleled in obstetrics, and unsurpassed in in ? precedent, and governing alike the juryman, ad- 
medicine. The reader's interest can never flag, so I vocate, and judge. —N. A. Med.-Chtr. Review. 



MOHR (FRANCIS), PH. D., AND REDWOOD (THEOPHI LUS). 

PRACTICAL PHARMACY. Comprising the Arrangements, Apparatus, and 
Manipulations of the Pharmaceutical Shop and Laboratory. Edited, with extensive Additions, 
by Prof. William Procter, of the Philadelphia College of Pharmacy. In one handsomely 
printed octavo volume, extra cloth, of 570 pages, with over 500 engravings on wood. $2 75 



WAYNE'S DISPENSATORY AND THERA- 
PEUTICAL REMEMBRANCER. With every 
Practical Formula contained in the three British 
Pharmacopoeias. Edited, with the addition of the 
Formula? of the U. S.. Pharmacopoeia, by R. E. 
©xiffixHjM.D 1 12mo.voi.ex.cl.,300pp. 75 c. 



MALGAIGNE'S OPERATIVE SURGERY, based 
on Normal and Pathological Anatomy. Trans- 
lated from the French by Frederick Brittan, 
A . B . , M . D . Wi th numerous il lustrations on wood . 
In one handsome octavo volume, extra cloth, of 
nearly gix hundred pages. 82 25. 



24 



BLANCHARD & LEA'S MEDICAL 



NEJLL (JOHN), M. D., 

Surgeon to the Pennsylvania Hospita^&c; and 

FRANCIS GURNEY SMITH, M.D., 

Professor of Institutes of Medicine in the Pennsylvania Medical College. 

AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES 

OF MEDICAL SCIENCE ; for the Use and Examination of Students. A new edition, revised 

and improved. In one very large and handsomely printed royal 12mo. volume, of about one 

thousand pages, with 374 wood-cuts. Strongly bound in leather, with raised bands. $3 25. 

This work is again presented as eminently worthy of the favor with which it has hitherto 

been received. As a book for daily reference by the student requiring a guide to his more elaborate 

text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate 

examination, or as a source from which the practitioners of older date may easily and cheaply acquire 

a knowledge of the changes and improvement in professional science, its reputation is permanently 

established. 



The best work of the kind with which we are 
acquainted. — Med. Examiner. 

Having made free use of this volume in our ex- 
aminations of pupils, we can speak from experi- 
ence in recommending it as an admirable compend 
for students, and as especially useful to preceptors 
who examine their pupils. It will save the teacher 
much labor by enabling him readily to recall all of 
the points upon which his pupils should be ex- 
amined. A work of this sort should be in the hands 
of every one who takes pupils into his office with a 
view of examining them ; and this is unquestionably 
thebestof its class. — Transylvania Med. Journal, 

In the rapid course of lectures, where work for 



the students is heavy, and review necessary for an 
examination, a compend is not only valuable, but 
it is almost a sine qua non. The one before us is, 
in most of the divisions, the most unexceptionable 
of all books of the kind that we know of. The 
newest and soundest doctrines and the latest im- 
provements and discoveries are explicitly, though 
concisely, laid before the student. There is a class 
to whom we very sincerely commend this cheap book 
as worth its weight in silver — that class is the gradu- 
ates in medicine of more than ten years' standing, 
who have not studied medicine since. They will 
perhaps find out from it that the science is not exactly 
now what it was when they left it off.— The Stetho- 
scope. 



NELIGAN (J. MOORE), M . D., M. R. I. A., &c. 
ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, extra 

cloth, with splendid colored plates, presenting nearly one hundred elaborate representations of 

disease. $4 50. 

This beautiful volume is intended as a complete and accurate representation of all the varieties 
of Diseases of the Skin. While it can be consulted in conjunction with any work on Practice, it has 
especial reference to the author's " Treatise on Diseases of the Skin," so favorably received by the 
profession some years since. The publishers feel justified in saying that few more beautifully exe- 
cuted plates have ever been presented to the profession of this country. 

Neligan's Atlas of Cutaneous Diseases supplies a 
long existent desideratum much felt by the largest 
class of our profession. It presents, in quarto size, 
16 plates, each containing from 3 to 6 figures, and 
forming in all a total of 90 distinct representations 
of the different species of skin affections, grouped 
together in genera or families. The illustrations 
have been taken from nature, and have been copied 
with such fidelity that they present a striking picture 
of life ; in which the reduced scale aptly serves to 



give, at a coup d'ail, the remarkable peculiarities 
of each individual variety. And while thus the dis- 
ease is rendered more definable, there is yet no loss 
of proportion incurred by the necessary concentra- 
tion. Each figure is highly colored, and so truthful 
has the artist been that the mostfastid ous observeT 
could not justly take exception to the correctness of 
the execution of the pictures under his scrutiny.— 
Montreal Med. Chronicle. 



BY THE SAME AUTHOR. 



A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Third 

American edition. In one neat royal 12mo. volume, extra cloth, of 334 pages. $1 00. 
The two volumes will be sent by mail on receipt of Five Dollars. 



OWEN ON THE DIFFERENT FORMS OF 
THE SKELETON, AND OF THE TEETH. 



One vol. royal 12mo., extra cloth with numerous 
illustrations. $1 25. 



PIRRIE (WILLIAM), F. R. S. E., 

Professor of Surgery in the University of Aberdeen. 

THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John 

Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon tothe Pennsylvania 
Hospital, &e. In one very handsome 8vo. volume, extra cloth, of 780 pages, with 316 illustrations. 
$3 75. 



We know of no other surgical work of a reason- 
able size, wherein there is so much theory and prac- 
tice, or where subjects are more soundly or clearly 
taught. — The Stethoscope. 

Prof. Pirrie, in the work before us, has elabo- 



rately discussed the principles of surgery, and a 
safe and effectual practice predicated upon them. 
Perhaps no work upon this subject heretofore issued 
is so full upon the science of the art of surgery. — 
Nashville Journal of Medicine and Surgery. 



PARKER (LANGSTON), 

Surgeon to the Queen's Hospital, Birmingham. 

THE MODERN TREATMENT OF SYPHILITIC DISEASES, BOTH PRI- 
MARY AND SECONDARY; comprising the Treatment of Constitutional and Confirmed Syphi- 
lis, by a safe and successful method. With numerous Cases, Formulae, and Clinical Observa- 
tions. From the Third and entirely rewritten London edition. In one neat octavo volume, 
extra cloth, of 316 pages. $175. 



AND SCIENTIFIC PUBLICATIONS. 



25 



PARRISH (EDV/ARD), 

Lecturer on Practical Pharmacy and Materia Medica in the Pennsylvania Academy of Medicine, &c. 

AN INTRODUCTION TO PRACTICAL PHARMACY. Designed as a Text- 
Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Fop- 
's mute and Prescriptions. Third edition, greatly improved. In one handsome octavo volume, 
of about 700 pages, with several hundred Illustrations. {Preparing for early 'publication.) 
Though for some time out of print, ihe appearance of a new edition of this work has been de- 
layed for the purpose of embodying in it the results of the new U. S. Pharmacopoeia. The ap- 
proaching publication of this latter will enable the author to complete his revision at an early pe- 
riod, when those who have been waiting for the work may rely on obtaining a volume thoroughly 
on a level with the most advanced condition of pharmaceutical science. 

The favor with which the work has thus far been received shows that the author was not mis- 
taken in his estimate of the want of a treatise which should serve as a practical text-book for all 
engaged in preparing and dispensing medicines. Such a guide was indispensable not only to the 
educated pharmaceutist, but also to that large class of practitioners throughout the country who 
are obliged to compound their own prescriptions, and who during their collegiate course have no 
opportunity of obtaining a practical familiarity with the necessary processes and manipulations. 
The rapid exhaustion of two large editions is evidence that the author has succeeded in thoroughly 
carrying out his object, and that the profession may rely that nolhing shall be wanting to render 
the new edition worthy a continuance of the confidence hitherto bestowed upon the work. 



All that we can say of it is that to the practising 
physician, and especially the country physician, 
who is generally his own apothecary, there is hard- 
ly any book that might not better be dispensed witn. 
It is at the same time a dispensatory and a pharma- 
cy. — Louisville Review. 

A careful examination of this work enables us to 
speak of it in the highest terms, as being the best 
treatise on practical pharmacy with which we are 
acquainted, and an invaluable vide-wecum, not only 
to the apothecary and to those practitioners who 
are accustomed to prepare tl eir own medicines, but 
to every medical man and medical student. — Boston 
Med. and Surg. Journal. 

This is altogether one of the most useful books 
we have seen. It is just what we have long felt to 
be needed by apothecaries, students, and practition- 
ers of medicine, most of whom in this country have 
to put up their own prescriptions. It bears, upon 
every page, the impress of practical knowledge, 
conveyed in a plain common sense manner, and 
adapted to the comprehension of all who may read 
it. No-detail has been omitted, however trivial it 
may seem, although really important to the dispenser 
of medicine — Southern Med. and Surg. Journal. 

That Edward Parrish, in writing a book upon 
practical Pharmacy some few years ago — one emi- 
nently original and unique — did the medical and 
pharmaceutical professions a great and valuable ser- 
vice, no one, we think, who has had access to its 



pages will deny; doubly welcome, then, is this new 
edition, containing the added results of his recent 
and rich experience as an observer, teacher, and 
practic il operator in the pharmaceutical laboratory. 
The excellent plan of the first is more thoroughly, 
and in detail, carried out in this edition. — Peninsular 
Med. Journal, Jan. I860. 

Of course, all apothecaries who have not already 
a copy of the first edition will procure one of this; 
it is, therefore, to physicians residing in the country 
and in small towns, who cannot avail themselves of 
the skill of an educated pharmaceutist, that we 
would espfcially commend this work. In it they 
will find all that they desire to know, and should 
know, but very little of which they do really Know 
in reference to this important collateral branch of 
their profession; for it is a well established fact, 
that, in the ecueation of physicians, while the sci- 
ence of medicine is generally well taught, very 
little attention is paid to the art of preparing them 
for use, and we know not how this defect can be so 
well remedied as by procuring and consulting Dr. 
Pairish's excellent work. — St. Louis Med. Journal. 
Jan. 1860. 

We know of no work on the subject which would 
be more indispensable to the physician or student 
desiring information on the subject of which it treats. 
With Griffith's " Medical Formulary" and this, the 
practising physician would be supplied with nearly 
or quite all the most useful information on the sub- 
ject. — Charleston Med. Jour .and Review , Jan. 1860. 



PEASLEE (E. R.), M. D., 

Professor of Physiology and General Pathology in the New York Medical College. 

HUMAN HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology j 
for the use of Medical Students. With four hundred and thirty- four illustrations. In one hand- 
some octavo volume, extra cloth, of over 600 pages. $3 75. 



It embraces a library upon the topics discussed 
within itself, and is just what the teacher and learner 
need. We have not only the whole subject of His- 
tology, interesting in itself, ably and fully discussed, 
but what is ot infinitely greater interest to the stu- 
dent, because of greater practical value, are its re- 
lations to Anatomy, Physiology, and Pathology, 
which are here fully and satisfactorily set forth.— 
Nashville Journ. of Med. and Surgery. 



We would recommend it as containing a summary 
of all that is known of the important subjects which 
it treats ; of all that is in the great works of Simon 
and Lehmann, and the organic chemists in general. 
Master this one volume, we would say to the medical 
student and practitioner — master this book and you 
know all that is known of the great fundamental 
principles of medicine, and we have to hesitation 
in saying that it is an honor to the American medi- 
cal profession. — St. Louis Mid. and Surg. Journal. 



ROKITANSKY (CARL), M.D., 

Curator of the Imperial Pathological Museum, and Professor at the University of Vienna, &c. 



A MANUAL OF PATHOLOGICAL 

bound in two, extra cloth, of about 1200 pages. 

king, C. H. Moore, and G. E. Day. $5 50. 

The profession is too well acquainted with the re- 
putation of Rokitansky's work to need our assur- 
ance that this is one of the most profound, thorough, 
and valuable books ever issued from the medical 
press. It is sui generis, and has no standard of com- 
parison. It is only necessary to announce that it iB 
issued in a form as cheap as is compatible with its 
size and preservation, and its sale follows as a 
matter of course. No library can be called com- 
plete without it. — Buffalo Med. Journal. 

An attempt to give our readers any adequate idea 
of the vast amount of instruction accumulated in 



ANATOMY. Four volumes, octavo, 
Translated by W. E. Swaine, Edward Sieve- 

these volumes, would be feeble and hopeless. The 
effort of the distinguished author to concentrate 
in a small space his great fund of knowledge, has 
so charged ms text witli valuable trutns, cnat any 
attempt of a reviewer to epitomize is at once para- 
lyzed, and must end in a failure. — Western Lancet. 
As this is the highest source of knowledge upon 
the important subject of which it treats, no real 
student can afford to be without it. The American 
publishers have entitled themselves to the thanks of 
the profession of their country, for this timeous and 
beautiful edition. — Nashville Journal of Medicin* 



26 



BLANCHARD & LEA'S MEDICAL 



RIGBY (EDWARD), M.D., 

Senior Physician to the General Lying-in Hospital, &c. 

A SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. 

Second American Edition. One volume octavo, extra cloth, 422 pages. $2 50. i 

BY THE SAME AUTHOR. 

ON THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES. 

In one neat royal 12mo. volume, extra cloth, of about 250 pages. $1 00. 



RAMSBOTHAM (FRANCIS H.), M.D. 
THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND 

SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly 
revised by the Author. With Additions by W. V. Keating, M. D., Professor of Obstetrics, &c, in 
the Jefferson Medical College, Philadelphia. In one large and handsome imperial octavo volume, 
of 650 pages, strongly bound in leather, with raised bands; with sixty- four beautiful Plates, and 
numerous Wood-cuts in the text, containing in all nearly 200 large and beautiful figures. $5 50. 

From Prof. Hodge, of the University of Pa. 
To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being 

the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout 

our country. 

truly elegant style in which they have brought it 
out, excelling themselves in its production, espe- 
cially in its plates. It is dedicated to Prof. Meigs, 
and has the emphatic endorsement of Prof. Hodge, 
as the best exponent of British Midwifery. We 
knew of no text-book which deserves in all respects 
to be more highly recommended to students, and we 
could wish to see it in the hands of every practitioner, 
for they will find it invaluable for reference.— Med. 
Gazette. 



It is unnecessary to say anything in regard to the 
utility of this work. It is already appreciated in our 
country for the value of the matter, the clearness of 
its style, and the fulness of its illustrations. To the 
physician's library it is indispensable, while to the 
student as a text-book, from which to extract the 
material for laying the foundation of an education on 
obstetrical science, it has no superior. — Ohio Med. 
and Surg. Journal. 

The publishers have secured its success by the 



RICORD (P.), M. D. 
A TREATISE ON THE VENEREAL DISEASE. By John Hunter, F. R. S. 

With copious Additions, by Ph. Ricord, M. D. Translated and Edited, with Notes, by Freeman 
J. Bumstead, M.D., Lecturer on Venereal at the College of Physicians and Surgeons, New York. 
Second edition, revised, containing a resume, of Ricord's Recent Lectures on Chancre. In 
one handsome octavo volume, extra cloth, of 550 pages, with eight plates. $3 25. 
Every one will recognize the attractiveness and 
value which this work derives from thus presenting 
the opinions of these two masters side by side. But, 
it must be admitted, what has made the fortune of 
the book, is the fact that it contains the "most com- 
plete embodiment of the veritable doctrines of the 
H6pital du Midi," which has ever been made pub- 

BY THE SAME AUTHOR. 

RICORD'S LETTERS ON SYPHILIS. Translated by W. P. Lattimore, M. D. 
In one neat octavo volume, of 270 pages, extra cloth. $2 00. 



lie. In conclusion we can say that this is incon* 
testablythe best treatise on syphilis with which we 
are acquainted, and, as we do not often employ the 
phrase, we may be excused for expressing the hope 
that it may find a place in the library of every phy- 
sician.— Virginia Med. and Surg. Journal. 



ROYLE'S MATERIA MEDICA AND THERAPEUTICS; including the 

Preparations of the Pharmacopoaias of London, Edinburgh, Dublin, and of the United States. 
With many new medicines. Edited by Joseph Carson, M. D. With ninety-eight illustrations. 
In one large octavo volume, extra cloth, of about 700 pages. $3 00. 



SMITH (HENRY H.), M. D., AND HORNER (W I L LI AM E.), M. D. 
AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. 
In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful 
figures. $3 50. 



The plan of this Atlas, which renders it so pe- 
culiarly convenient for the student, and its superb 
artistical execution, have been already pointed out. 
We must congratulate the student upon the comple- 
tion of this Atlas, as it is the most convenient work 



of the kind that has yet appeared ; and we must add, 
the very beautiful manner in which it is " got up'* 
is so creditable to the country as to be flattering 
to our national pride. — American Medical Journal. 



SHARPEY (WILLIAM), M. D., JONES QUAIN, M. D., AND 
RICHARD QUAIN, F. R. S., &c. 

HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidy^ 

M. D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octavo 
volumes, extra cloth, of about thirteen hundred pages. With over 500 illustrations. $6 00. 



SOLLY ON THE HUMAN BRAIN; its Structure, 
Physiology, and Diseases. From the Second and 
much enlarged London edition. In one octavo 
volume, extra cloth, of 500 pages, with 120 wood- 
cuts. $2 00. 

SKEY'S OPERATIVE SURGERY. In one very 



handsome octavo volume, extra cloth, of over 65© 
pages, with about one hundred wood-cuts. $3 25. 
SIMON'S GENERAL PATHOLOGY, as conduc- 
ive to the Establishment of Rational PrineipleB 
for the prevention ano Cure of Disease la one 
octavo volume, extra cloth, of 212 pages. $1 25. 



AND SCIENTIFIC PUBLICATIONS. 



27 



STILLE (ALFRED), M. D. 
THERAPEUTICS AND MATERIA MEDIC A; a Systematic Treatise on the 

Action and Uses of Medicinal Agents, including their Description and History. In two large 

and handsome octavo volumes, of 1789 pages, leather. $8 00. 

This work is designed especially for the student and practitioner of medicine, and treats the various 
articles of the Materia Medica from the point of view of the bedside, and not of the shop or of the 
lecture-room. While thus endeavoring to give all practical information likely to be useful with 
respect to the employment of special remedies in special affections, and the results to be anticipated 
from their administration, a copious Index of Diseases and their Remedies renders the work emi- 
nently fitted for reference by showing at a glance ihe different means which have been employed, 
and enabling the practitioner to extend his resources in difficult cases with ail that the experience 
of the profession has suggested. 



Rarely, indeed, have we had submitted to us a 
work on medicine so ponderous in its dimensions 
as that now before us, and yet so fascinating 'in its 
contents. It is, therefore, with a peculiar gratifi- 
cation that we recognize in Dr. Stille the posses- 
sion of many of those more distinguished qualifica- 
tions which entitle him to approbation, and which 
]ustify him in coming before his medical brethren 
as an instructor. A comprehensive knowledge, 
tested by a sound and penetrating judgment, joined 
to a love of progress — which a discriminating spirit 
of inquiry has tempered so as to accept nothing new 
because it is new, and abandon nothing old because 
it is old, but which estimates either accort ing to its 
relations to a just logic and experience— manifests 
itself everywhere, and gives to the guidance of the 
author all f he assurance of safety which the diffi- 
culties of his subject can allow. In conclusion, we 
earnestly advise our readers to ascertain for them- 
selves, by a study of Dr. Stille's volumes, the great 
value and interest of the stores of knowledge they 
present. We have pleasure in referring rather to 
the ample treasury of undoubted truths, the real and 
assured conquest of medicine, accumulated by Dr. 
Stille in his pages ; and commend the sum of his la- 
bors to the attention of our readers, as alike honor- 
able to our science, and creditable to the zeal, the 
candor, and the judgment of him who has garnered 
the whole so carefully. — Edinburgh Med. Journal. 

Our expectations of the value of this work were 
based on the well-known reputation and character 
of the author as a man of scholarly attainments, an 
elegant writer, a candid inquirer after truth, and a 
philosophical thinker ; we knew that the task would 
be conscientiously performed, and that few, if any, 
among the distinguished medical teachers in this 
country are better qualified than he to prepare a 
systematic treatise on therapeutics in accordance 
with the present requirements of medical science. 
Our preliminary examination of the work has satis- 



fied us that we were not mistaken in our anticipa- 
tions. — New Orleans Medical News, March, 1S60. 

The most recent authority is the one last men- 
tioned, Stille. His great work on " Materia Medi- 
ca and Therapeutics," published last year, in two 
octavo volumes, of some sixteen hundred pages, 
while it embodies the results of the labor of others 
up to the time of publication, is enriched with a 
great amount of original observation and research. 
We would draw attention, by the way, to the very 
convenient mode in which the Index is arranged in 
this work. There is firstan " Index of Remedies ;" 
next an " Index of Diseases and their Remedies." 
Such an arrangement of the Indices, in our opinion, 
greatly enhances the practical value of books of this 
kind. In tedious, obstinate cases of disease, where 
we have to try one remedy after another until our 
stock is pretty nearly exhausted, and we are almost 
driven to our wit's end, such an index as the second 
of the two just mentioned, is precisely what we 
want. — London Med. Times and Gazette, April, 1861. 

We think this work will do much to obviate the 
reluctance to a thorough investigation of this branch 
of scientific study, for in the wide range of medical 
literature treasured in the English tongue, we shall 
hardly find a work written in a style more clear and 
simple, conveying forcibly the facts taught, and yet 
free from turgidity and redundancy. There is a fas- 
cination in its pages that will insure to it a wide 
popularity and attentive perusal, and a degree of 
usefulness not often attained through the influence 
of a single work. The author has much enhanced 
the practical utility of his book by passing briefly 
over the physical, botani jal, and commercial history 
of medicines, and directing attention chiefly to their 
physiological action, and their application for the 
amelioration or cure of disease. He ignores hypothe- 
sis and theory which are so alluring to many medical 
writers, and so liable to lead them astray, and con- 
fines himself to such facts as have been tried in the 
crucible of experience. — Chicago Medical Journal. 



SIMPSON (J. Y.), M. D., 
Professor of Midwifery, &c, in the University of Edinburgh, &c. 

CLINICAL LECTURES ON THE DISEASES OF WOMEN. With nu- 

meious illustrations. In one handsome octavo volume, of over 500 pages, extra cloth, $3 00. 

(Now Ready, 1863.) 

This valuable work having passed through the columns of " The Medical News and Library" 
tor I860, 18bl, and 1862, is now completed, and may be had separate in one handsome volume. 

These Lectures were delivered by Professor Simpson at the Royal Infirmary of Edinburgh and 
were published in the " London Medical Times and Gazette" during the years 1859, 1860, and 1861. 
The distinguished reputation of the author, and the valuable practical matter contained in the Lec- 
tures have >eemed to entitle them to a more permanent form than the evanescent pages of a peri- 
odical. Embracing a wide range of subjects, and each one elaborately treated and complete in 
itself, the volume can hardly fail to prove a valuable addition to the library of the practising phy- 
sician. 

The principal topics embraced in the Lectures are Vesico-Vaginal Fistula, Cancer of the Uterus, 
Treatment of Carcinoma by Caustics, Dysmenorrhea, Amenorrhea, Closures, Contractions, &c, 
of the Vagina, Vulvitis, Causes of Death after Surgical Operations, Surgical Fever, Phlegmasia 
Dolens, Coccyodinia, Pelvic Cellulitis, Pelvic Hematoma, Spurious Pregnancy, Ovarian Dropsy, 
Ovariotomy, Cranioclasm, Diseases of the Fallopian Tubes, Puerperal Mania, Sub-Involution and 
Super-Involution of the Uterus, &c. &c. 

As a series of monographs on these important topics — many of which receive little attention 
in the ordinary text-books — elucidated with the extensive experience and readiness of resource for 
which Professor Simpson is so distinguished, there are few practitioners who will not find in its 
pages matter of the utmost importance in the treatment of obscure and difficult cases. 



SALTER (H. H.), M. D. 



ASTHMA; its Pathology, Causes, Consequences, and Treatment. (Now pub- 
iisliing in the " Medical News and Library" for 1863.) To form one volume, 8vo. 



23 



BLANCHARD & LEA'S MEDICAL 



SARGENT (F. W.), M. D. 
ON BANDAGING AND OTHER OPERATIONS OF MINOR SURGERY. 

New edition, with an additional chapter on Military Surgery. One handsome royal 12mo. vol., 
of nearly 400 pages, with 184 wood cuts. Extra cloth, $1 50. {Now Ready.) 
The value of this work as a handy and convenient manual for surgeons engaged in active duty, has 
induced the publishers to render it more complete for those purposes by the addition of a chapter 
on gun-shot wounds and other matters peculiar to military surgery. In its present form, there- 
fore, with no increase in price, it will be found a very cheap and convenient vade-mecum for con- 
sultation and reference in the daily exigencies of military as well as civil practice. 

We consider that no better book could be placed 
in the hands of an hospital dresser, or the young sur- 
geon, whose education in this respect has not been 
perfected . We most cordially commend this volume 
as one which the medical student should most close- 



ly study, to perfect himself in these minor surgical 
operations in which neatness and dexterity are so 
much required, and on which a great portion of his 
reputation as a future surgeon must evidently rest. 
And to the surgeon in practice it must prove itself 
a valuable volume, as instructive on many points 
which he may have forgotten. — British American 
Journal, May, 1862. 



The instruction given upon the subject of Ban- 
daging, is alone of great value, and while the author 
modestly proposes to instruct the students of medi- 
cine, and the younger physicians, we will say that 
experienced physicians will obtain many exceed- 
ingly valuable suggestions by its perusal. It will 
be found one of the most satisfactory manuals for re- 
ference in the field, or hospital yet published ; thor- 
oughly adapted to the wants of Military surgeons, 
and at the same time equally useful for Teauy and 
convenient reference by surgeons everywhere. — 
Buffalo Med. and Surg. Journal, June, 1862. 



SMITH (W. TYLER), M. D., 

Physician Accoucheur to St. Mary's Hospital, &c. 

ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OF 

OBSTETRICS. In one royal 12mo. volume, extra cloth, of 400 pages. $1 25. 

BY THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE PATHOLOGY AND TREATMENT 

OF LEUCORRHCEA. With numerous illustrations. In one very handsome octavo volume, 
extra cloth, of about 250 pages. $1 50. 

TANNER (T. H.), M. D., 

Physician to the Hospital for Women, &c. 

A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS. 

To which is added The Code of Ethics of the American Medical Association. Second 
American Edition. In one neat volume, small 12mo., extra cloth, 87£ cents. 

TAYLOR (ALFRED S.), M. D., F. R. S., 

Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital. 

MEDICAL JURISPRUDENCE. Fifth American, from the seventh improved 

and enlarged London edition. With Notes and References to American Decisions, by Edward 
Hartshorne, M. D. In one large 8vo. volume, extra cloth, of over 700 pages. $3 25. 
This standard work having had the advantage of two revisions at the hands of the author since 
the appearance of the last American edition, will be found thoroughly revised and brought up com- 
pletely to the present state of the science. As a work of authority, it must therefore maintain its 
position, both as a text-book for the student, and a compendious treatise to which the practitioner 
can at all times refer in cases of doubt or difficulty. 



No work upon the subject can be put into the 
hands of students either of law or medicine which 
will engage them more closely or profitably; and 
none could be offered to the busy practitioner of 
either calling, for the purpose of casual or hasty 
reference, that would be more likely toafford the aid 
desired. We therefore recommend it as the best and 
safest manual for daily use.— American Journal oj 
Medical Sciences. 

It is not excess of praise to say that the volume 
before us is the very best treatise extant on Medical 
Jurisprudence. In saying this, we do not wish to 
be understood as detracting from the merits of the 
excellent works of Beck, Ryan, Traill, Guy, and 
others; but in interest and value we think it must 
be conceded that Taylor is superior to anything that 
has preceded it. — N. W. Medical and Surg. Journal 

It is at once comprehensive and eminently prac- 
tical, and by universal consent stands at the head of 

BY THE SAME AUTHOR. 

ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND 

MEDICINE. Second American, from a second and revised London edition. In one large 

octavo volume, oi 755 pages, extra cloth. $3 50. 

Mr. Taylor's position as the leading medical jurist of England, has conferred on him extraordi- 
nary advantages in acquiring experience on these subjects, nearly all cases of moment being 
referred to him for examination, as an expert whose testimony is generally accepted as final. 
The results of his labors, therefore, as gathered together in this volume, carefully weighed and 
snted, and presented in the clear and intelligible style for which he is noted, may be received 
as an acknowledged authority, and as a guide to be followed with implicit confidence. 



American and British legal medicine. It should be 
in the possession of every physician, as the subject 
is one of great and increasing importance to the 
public as well as to the profession.— St. Louis Med. 
and Surg. Journal. 

This work of Dr. Taylor's ie generally acknow- 
ledged to be one of the ablest extant on the subject 
of medical jurisprudence. It is certainly one of the 
most attractive books that we have met with ; sup- 
plying so much both to interest and instruct, that 
we do not hesitate to affirm that after having once 
commeilced its perusal, few could be prevailed upon 
to desist before completing it. In the last London 
edition, all the newly observed and accurately re- 
corded facts have been inserted, including much 
that is recent of Chemical, Microscopical, and Pa- 
thological research, besidts papers on numerous 
subjects never before published. — Charleston Med. 
Journal and Review. 



CHEMISTRY. 



BV THE SAME AUTHOR AND WM BRANDE. 

In one volume 8vo. See "Brande," p 



6. 



AND SCIENTIFIC PUBLICATIONS. 29 

TODD (ROBERT BENTLEY), M . D., F. R. S., 

Professor of Physiology in King's College, London; and 
WILLIAM BOWMAN, F. R. S., 

Demonstrator of Anatomy in King's College, London. 

THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With 

about three hundred large and beautiful illustrations on wood. Complete in one large octavo 
volume, of 950 pages, extra cloth. Price $4 50. 



It is more concise than Carpenter's Principles, and 
more modern than the accessible edition of Muller's 
Elements; its details are brief, but sufficient; its 
descriptions vivid ; its illustrations exact and copi- 
ous ; and its language terse and perspicuous. — 
Charleston Med. Journal. 



A magnificent contribution to British medicine, 
and the American physician who shall fail to peruse 
it, will have failed to read one of the most instruc- 
tive books of the nineteenth century. — N. O. Med. 
and Surg. Journal. 



TODD (R. B.) M. D., F. R. S., &c. 
CLINICAL LECTURES ON CERTAIN DISEASES OF THE URINARY 

ORGANS AND ON DROPSIES. In one octavo volume, 284 pages, extra cloth. $1 50. 

BY THE SAME AUTHOR. 

CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one neat 

octavo volume, of 320 pages, extra cloth. $1 75. 



TOYNBEE (JOSEPH), F. R. S., 

Aural Surgeon to, and Lecturer on Surgery at, St. Mary's Hospital. 

A PRACTICAL TREATISE ON DISEASES OF THE EAR; their Diag- 

nosis, Pathology, and Treatment. Illustrated with one hundred engravings on wood. In one 
very handsome octavo volume, extra cloth, $3 00 



The work is a model of its kind, and every page 
and paragraph ot it are worthy of the most thorough 
study. Considered all in all — as an original work, 
well written, philosophically elaborated, and happi- 
ly illustrated with cases and drawings— it is by far 
the ablest monograph that has ever appeared on the 
anatomy and diseases of the ear, and one of the most 
valuable contributions to the art and science of sur- 
gery in the nineteenth century.— N. Amer. Medico- 
Chirurg. Review, Sept. 1860. 

We are speaking within the limits of modest ac- 
knowledgment, and with a sincere and unbiassed 
judgment, when we affirm that as a treatise on Aural 



Surgery, it is without a rival in our language or any 
other.— Charleston Med. Journ. and Rev., Sept. I860. 
The work of Mr. Toynbee is undoubtedly, upon 
the whole, the most valuable produciion of the kind 
in any language. The author has long been known 
by his numerous monographs upon subjects con- 
nected with diseases of the ear, and is now regarded 
as the highest authority on most points in his de- 
partment of science. Mr. Toynbee's work, as we 
have already said, is undoubteuly the most reliable 
guide for the study of the diseases of the tar in any 
language, and should be in the library of every ptiy- 
sician.— Chicago Med. Journal, July, 1860. 



WILLIAMS (C. J. B.), M.D., F. R. S., 

Professor of Clinical Medicine in University College, London, &c. 

PRINCIPLES OF MEDICINE. An Elementaiy Yiew of the Causes, Nature, 

Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, or the pre- 
servation of health. A new American, from the third and revised London edition. In one octavo 
volume, extra cloth, of. about 500 pages. $2 50. 



WHAT TO OBSERVE 
AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. 

Published under the authority of the London Society for Medical Observation. A new American, 

from the second and revised London edition. In one very handsome volume, royal 12mo., extra 

cloth. $1 00. 

To the observer who prefers accuracy to blunders I One of the finest aids to a young practitioner wo 
and precision to carelessness, this little book is in- have ever seen. — Peninsular Journal of Mtdicine. 
valuable. — N. H. Journal of Medicine. I 



WALSHE (W. H.), M. D., 

Professor of the Principles and Practice of Medicine in University College, London, &c. 

A PRACTICAL TREATISE ON DISEASES OF THE LUNGS; including 

the Principles of Physical Diagnosis. Third American, from the third revised and much en- 
larged London edition. In one vol. octavo, of 468 pages, extra cloth. $2 25. 
The present edition has been carefully revised and much enlarged, and may be said in the main 
to be rewritten. Descriptions of several diseases, previously omitted, are now introduced ; an 
effort has been made to bring the description of anatomical characters to the level of the wants of 
the practical physician ; and the diagnosis and prognosis of each complaint are more completely 
considered. The sections on Treatment and the Appendix have, especially, been largely ex- 
tended. — Azcthor's Preface. 

BY THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE DISEASES OF THE HEART AND 

GREAT VESSELS, including the Principles of Physical Diagnosis. Third American, from the 

third revised and much enlarged London edition. In one handsome octavo volume of 420 pages, 

extra cloth. $2 25. 

The present edition has been carefully revised ; much new matter has been added, and the entire 
work in a measure remodelled. Numerous facts and discussions, more or less completely novel, 
will be found in the description of the principles of physical diagnosis ; but the chief additions have 
been made in the practical portions of the book. Several affections, of which little or no account 
had been given in the previous editions, are now treated of in detail. — Author's Preface. 



30 



BLANCHARD & LEA'S MEDICAL 



New and much enlarged edition. 

WATSON (THOMAS), M.D., &c, 

Late Physician to the Middlesex Hospital, &c. 

LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. 

Delivered at King's College, London. A new American, from the last revised and enlarged 

English edition, with Additions, by D. Francis Condie, M. D., author of " A Practical Treatise 

on the Diseases of Children," &c. With one hundred and eighty.five illustrations on wood. In 

one very large and handsome volume, imperial octavo, of over 1200 closely printed pages in 

small type ; the whole strongly bound in leather, with raised bands. Price $5 00. 

That the high reputation of this work might be fully maintained, the author has subjected it to a 

thorough revision ; every portion has been examined with the aid of the most recent researches 

in pathology, and the results of modern investigations in both theoretical and practical subjects 

have been carefully weighed and embodied throughout its pages. The watchful scrutiny of the 

editor has likewise introduced whatever possesses immediate importance to the American physician 

in relation to diseases incident to our climate which are little known in England, as well as those 

points in which experience here has led to different modes of practice ; and he has also added largely 

to the series of illustrations, believing that in this manner valuable assistance may be conveyed to 

the student in elucidating the text. The work will, therefore, be found thoroughly on a level with 

the most advanced state of medical science on both sides of the Atlantic. 

The additions which the work has received are shown by the fact that notwithstanding an en- 
largement in the size of the page, more than two hundred additional pages have been necessary 
to accommodate the two large volumes of the London edition (which sells at ten dollars), withm 
the compass of a single volume, and in its present form it contains the matter of at least three 
ordinary octavos. Believing it to be a work which should lie on the table of every physician, and 
be in the hands of every student, the publishers have put it at a price within the reach of all, making 
it one of the cheapest books as yet presented to the American profession, while at the same time 
the beauty of its mechanical execution renders it an exceedingly attractive volume. 



The fourth edition now appears, so carefully re- 
vised, as to add considerably to the value of a book 
already acknowledged, wherever the English lan- 
guage is read, to be beyond all comparison the best 
systematic work on the Principles and Practice of 
Physic in the whole range of medical literature. 
Every lecture contains proof of the extreme anxiety 
of the author to keep pace with ihe advancing know- 
ledge of the day One scarcely knows whether 
to admire most the pure, simple, forcible English — 
the vast amount of useful practical information 
condensed into the Lectures— or the manly, kind- 
hearted, unassuming character of the lecturer shin- 
ing through his work. — Lond. Med. Times. 

Thus these admirable volumes come before the 
profession in their fourth edition, abounding in those 
distinguished attributes of moderation, judgment, 
erudite cultivation, clearness, and eloquence, with 
which they were from the first invested, but yet 
richer than before in the results of more prolonged 
observation, and in the able appreciation of the 
latest advances in pathology and medicine by one 
of the most profound medical thinkers of the day. — 
London Lancet. 



The lecturer's skill, his wisdom, his learning, are 
equalled by the ease of his graceful diction, his elo- 
quence, and the far higher qualities of candor, of 
courtesy, of modesty, and of generous appreciation 
of merit in others. — N. A. Med.-Chir Review. 

Watson's unrivalled, perhaps unapproachable 
work on Practice — the copious additions made to 
which (the fourth edition) have given it all the no- 
velty and much of the interest of a new book. — 
Charleston Med. Journal. 

Lecturers, practitioners, and students of medicine 
will equally hail the reappearance of the work of 
Dr. Watson in the form of anew — a fourth— edition. 
We merely do justice to our own feelings, and, we 
are sure, of the whole profession, if we thank him 
for having, in the trouble and turmoil of a large 
practice, made leisure to supply the hiatus caused 
by the exhaustion of the third edition. For Dr. 
Watson has not merely caused the lectures to be 
reprinted, but scattered through the whole work we 
find additions or alterations which prove that the 
author has in every way sought to bring up his teach- 
ing to the level of the most recent acquisitions in 
science. — Brit, and For. Medico- Chir .Review . 



Hew and much enlarged edition. 

WILSON (ERASMUS), F. R. S. 

A SYSTEM OF HUMAN ANATOMY, General and Special. A new and re- 

vised American, from the last and enlarged English Edition. Edited by W. H. Gobrecht, M. D., 
Professor of Anatomy in the Pennsylvania Medical College, &c. Illustrated with three hundred 
and ninety-seven engravings on wood. In one large and exquisitely printed octavo volume, oi 
over 600 large pages; leather. $3 75. 

The publishers trust that the well earned reputation so long enjoyed by this work will be more 
than maintained by the present edition. Besides a very thorough revision by the author, it has been 
most carefully examined by the editor, and the efforts of both have been directed to introducing 
everything which increased experience in its use has suggested as desirable to render it a complete 
text-book for those seeking to obtain or to renew an acquaintance with Human Anatomy. The 
amount of additions which it has thus received may be estimated from the fact that the present 
edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged 
page requisite to keep the volume within a convenient size. The editor has exercised the utmost 
caution to obtain entire accuracy in the text, and has largely increased the number of illustra- 
tions, of which there are about one hundred and fifty more in this edition than in the last, thus 
bringing distinctly before the eye of the student everything of interest or importance. 

beauty of its mechanical execution, and the clear- 



It may be recommended to the student as no less 
distinguished by its accuracy and clearness of de- 
scription than by its typographical elegance. The 
wood-cuts are exquisite.— Brit, and For. Medical 
Review. 

An elegant edition of one of the most useful and 
accurate systems of anatomical science which has 
been issued from the press The illustrations are 
really beautiful. In its style the work is extremely 
concise and intelligible. No one can possibly take 
up this volume without being struck with the great 



ness of the descriptions which it contains is equally 
evident. Let students, by all means examine tfte 
claims of this work on their notice, before chey pur- 
chase a text-book of the vitally important science 
which this volume so fully and easily unfolds. — 
Lancet. 

We regard it as the best system now extant for 
students. — Western Lancet. 

It therefore receives our highestcommendation.— 
Southern Med. and Surg. Journal. 



AND SCIENTIFIC PUBLICATIONS 



31 



WILSON (ERASMUS), F. R. S. 
ON DISEASES OF THE SKIN. Fifth American, from the Fifth enlarged 

London edition. In one handsome octavo volume, of nearly 700 large pages, with illustrations 

on wood, extia cloth. $3 25. (Now Ready, May, 1863.) 

This classical work, which for twenty years has occupied the position of the leading authority 
in the English language on its important subject, has just received a thorough revision at the hands 
of the author, and is now presented as embodying the results of the latest investigations and expe- 
rience on all matters connected with diseases of the skin. The increase in the size of the work 
shows the industry of the author, and his determination that it shall maintain the position which it 
has acquired as thoroughly on a level with the most advanced condition of medical science. 

A few notices of the last edition are appended. 



The writings of Wilson, upondiseasesof the skin, 
are by far the most scientific and practical that 
have ever been presented to the medical world on 
this subject. The present edition isa great improve- 
ment on all its predecessors. To dwell upon all the 
great merits and high claims of the work before us, 
seriatim, would indeed be an agreeable service; it 
would be a mental homage which we could freely 
offer, but we should thus occupy an undue amount 
of space in this Journal. We will, however, look 
at some of the more salient points with which it 
al><mnds,and which make itincomparaoiy superior to 
all other treatises on the subject of dermatology. No 
mere speculative views are allowed a place in this 
volume, which, without a doubt, will, for a very long 
period, be acknowledged as the chief standard work 
on -dermatology. The principles of an enlightened 
and rational therapeia are introduced on every ap- 
propriate occasion. — Am. Jour. Med. Science. 

When the first edition of this work appeared; 
about fourteen years ago, Mr. Erasmus Wilson had 
already given some years to the study of Diseases 
of the Skin, and he then expressed his intention of 
devoting his future life to the elucidation of this 
branch of Medical Science. In the present edition 
Mr. Wilson presents us with the results of his ma- 
tured experience, and we have now before us not 
merely a reprint of his former publications, but an 
entirely new and rewritten volume. Thus, the whole 
history of the diseases affecting the skin, whether 
they originate in that structure ur are the mere mani- 
festations of derangement of internal organs, is 
brought under notice, and the book includes a mass 
of information which is spread over a great part of 
the domain of Medical and Surgical Pathology. We 
can safely recommend it to the profession as the 
best work on the subject now in existence in the En- 
glish language.; — London Med. Times and Gazette. 



No matter -what other treatises may be in the libra- 
ry of the medical attendant, he needs the clear and 
suggestive counsels of Wilson, who is thoroughly 
posted up on all subjects connected with cutaneous 
pathology. We have, it is very true, other valuable 
works on the maladies that invade the skin; but, 
compared with the volume under consideration, they 
are certainly to be regarded as inferior lights in guid- 
ing the judgment of the medical man. — Boston Med. 
and Surg. Journal, Oct. 1S57. 

The author adopts a simple and entertaining style. 
He strives to clear away the complications of his 
subject, and has thus produced a book filled with a 
vast amount of information, in a form so agreeable 
as to make it pleasant reading, even to the uninitiated. 
More especially does it deserve our praise because of 
its beautiful and complete atlas, which the American 
publishers have successfully imitated from the origi- 
nal plates. We pronounce them by far the best imi- 
tations of nature yet published in our country. With 
the text-book and atlas at hand, the diagnosis is ren- 
dered easy and accurate, and the practitioner feels 
himself safe in his treatment. We will add that this 
work, although it must have been very expensive to 
the publishers, is not high priced. There is no rea- 
son, then, to prevent every physician from obtaining 
a work of such importance, and one which will save 
him both labor and perplexity. — Va. Med. Journal. 

As a practical guide to the classification, diagnosis, 
and treatment of the diseases of the skin, the book is 
complete. We know nothing, considered in this as- 
pect, better in our language ; it is a safe authority on 
all the ordinary matters which, in this range of dis- 
eases, engage the practitioner's attention, and pos- 
sesses the high quality — unknown, we believe, to 
every older manual, of being on a level with science's 
high-water mark ; a sound book of practice. — London 
Med. Times. 



ALSO, NOW READY, 

A SERIES OF PLATES ILLUSTRATING WILSON ON DISEASES OF 

THE SKIN; consisting of twenty beautifully executed plates, of which thirteen are exquisitely 
colored, presenting the Normal Anatomy and Pathology of the Skin, and containing accurate re- 
presentations of about one hundred varieties of disease, most of them the size of nature. Price 
in cloth. $4 50. 

In beauty of drawing and accuracy and finish of coloring these plates will be found equal to 
anything of the kind as yet issued in this country. The value of the new edition is enhanced by 
an additional colored plate. 

We have already expressed our high appreciation 
of Mr. Wilson's treatise on Diseases of the Skin. 
The plates are comprised in a separate volume, 
which we counsel all those who possess the text to 
purchase. It is a beautiful specimen of color print- 
ing, and the representations of the various forms of 
skin disease are as faithful as is possible in plates 
of the size.— Boston Med. and Surg. Journal, April 
8, 1858. 



The plates by which this edition is accompanied 
leave nothing to be desired, so far as excellence of 
delineation and perfect accuracy of illustration are 
concerned. — Medico-Chirurgical Review. 
. Of these platesitisimpossible to speak too highly. 
The representations of the various forms of cutane- 
ous disease are singularly accurate, and the color- 
ing exceeds almost anything we have met with. — 
British, and Foreign Medical Review. 

Also, the TEXT and PLATES done up in one handsome volume, extra cloth, price $7 50. 

BY THE SAME AUTHOR. 

THE DISSECTOR'S MANUAL; or, Practical and Surgical Anatomy. Third 
American, from the last revised and enlarged English edition. Modified and rearranged, by 
William Hunt, M. D., Demonstrator of Anatomy in the University of Pennsylvania. In one 
large and handsome royal 12mo. volume, extra cloth, of 582 pages, with 154illustrations. $2 00. 

BY THE SAME AUTHOR. 

ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON 

SYPHILITIC ERUPTIONS. In one small octavo volume, extra cloth, beautifully printed, with 
four exquisite colored plates, presenting more than thirty varieties of syphilitic eruptions. $2 25, 

BY THE SAME AUTHOR. 

HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preserva- 
tion and Management. Second American, from the fourth London edition. One neat volume, 
royal 12mo. 5 extra cloth, of about 300 pages, with numerous illustrations. $1 00 ; paper cover, 
75 cents. 



32 



BLANCHARD & LEA'S MEDICAL PUBLICATIONS. 



WINSLOW (FORBES), M.D., D. C. L., &c. 
ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS OF THE 

MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Prophylaxis. In one 
handsome octavo volume, of nearly 600 pages, extra cloth. $3 00. 

Pathology. It completely exhausts the subject, in 



We close this brief and necessarily very imperfect 
notice of Dr. Winslow's great and classical work, 
by expressing our conviction that it is long since so 
important and beautifully written a volume has is- 
sued from the British medical press. — Dublin Med. 
Press, July 25, I860. 

We honestly believe this to be the best book of the 
season.— banking's Abstract, July, 1880. 

The latter portion of Dr. Winslow's work is ex- 
clusively devoted to the consideration of Cerebral 



the same manner as the previous seventeen chapters 
relating to morbid psychical phenomena left nothing 
unnoticed in reference to the mental symptoms pre- 
monitory of cerebral disease. It is impossible to 
overrate the benefits likely to result from a general 
perusal of Dr. Winslow's valuaole and deeply in- 
teresting work.— London Lancet, June 23, 1860. 

It contains an immense mass of information. 

Brit, and For. Med.-Chir. Review, Oct. 1S60. 



WEST (CHARLES), M. D., 

Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for 

Sick Children, &c. 

LECTURES ON THE DISEASES OF WOMEN. Second American, from the 

second London edition. La one handsome octavo volume, extra cloth, of about 500 pages ; 
price $2 50. 
*\£* Gentlemen who received the first portion, as issued in the " Medical News and Library," can 
now complete their copies by procuring Part II, being page 309 to end, with Index, Title matter, 
&c., 8vo., cloth, price $1. 



We mustnow conclude this hastily written sketch 
with the confident assurance to our readers that the 
work will well repay perusal. The conscientious, 
painstaking, practical physician isapparent on every 
page. — N. Y. Journal of Medicine. 

We know of no treatise of the kind so complete 
and yet so compact. — Chicago Med. Jour. 

A fairer, more honest, more earnest, and more re- 
liable investigator of the many diseases of women 
and children is not to be found in any country.— 
Southern Med. and Surg. Journal. 

We have to say of it, briefly and decidedly, that 
it is the best work on the subject in any language; 
and that it stamps Dr. West as the facile princeps 
of British obstetric authors. — Edinb. Med. Journ. 



We gladly recommend his Lectures as in the high- 
est degree instructive to all who are interested in 
obstetric practice. — London Lancet. 

Happy in his simplicity of manner, and moderate 
in his expression of opinion, the author is a sound 
reasoner and a good practitioner, and his book is 
worthy of the handsome garb in which it has ap- 
peared. — Virginia Med. Journal. 

We must take leave of Dr. West's very useful 
work, with our commendation of the clearness of 
its style, and the incustry and sobriety of judgment 
of which it gives evidence.— London Med Times. 

Sound judgment and good sense pervade every 
chapter of the book. From its perusal we have de- 
rived unmixed satisfaction.— Dublin Quart. Journ. 



BY THE SAME AUTHOR. 



LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. 

Third American, from the fourth enlarged and improved London edition. In one handsome 
octavo volume, extra cloth, of about six hundred and fifty pages. $i 75. 



The three former editions of the work now before 
us have placed the author in tfte foremost rank of 
those physicians who have devoted special attention 
to the diseases of early life We attempt no ana- 
lysis of this edition, but may refer the reader to some 
of the chapters to which the largest additions have 
been made — those on Diphtheria, Disorders of the 
Mind, and Idiocy, for instance — as a prooi that the 
work is really a new edition; not a mere reprint. 
In its present shape it will be lound of the greatest 
possible service in the every-day practice of nine- 
tenths of the profession. — Med. Times and Gazette, 
London, Dec. 10, 1859. 

All things considered, this book of Dr. West is 
by far the best treatise in our language upon such 
modifications of morbid action and disea.se as are 
witnessed when we have to deal with infancy and 
childhood. It is true that it confines itself to such 
disorders as come within the province of the phy- 
sician, and even with respect to these it is unequal 
as regards minutentss of consideration, and some 

BY THE SAME AUTHOR. 

AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCER- 

ATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 00. 



diseases it omits to notice altogether. But those 
who know anything of the present condition oi 
paediatrics will readily admit that it would be next 
to impossible to effect more, or effect it better, than 
the accoucheur of St. Bartholomew's has done in a 
single volume. The lecture (XVI.) upon Disorders 
of the Mind in chiluren is an admirable specimen of 
the value oi the later information convejed in the 
Lectures of Dr. Charles West. — London Lancet, 
Oct. 22, 1859. 

Since the appearance of the first edition, about 
eleven years ago, the experience of the author has 
doubled ; so that, whereas the lectures at first were 
founded on six hundred observations, and one hun- 
dred and eigui y dissections made among nearly four- 
teen tnousaiid children, they now embody the results 
of nine hundred observations, and two hundred and 
eighty-eight post- mortem examinations made among 
nearly thirty thousand children, who, during the 
past twt*i, ty years, have been under his care. — 
British Med. Journal, Oct. 1, 1859. 



WHITEHEAD ON THE CAUSES AND TREAT- 
MENT OF ABORTION AND STERILITY. 



Second American Edition. In one volume, octa- 
vo extra cloth, pp. 308. 91 75. 



LIBRARY OF CONGRESS *| 

022 169 838 1 



